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Lim HS, González-Costello J, Belohlavek J, Zweck E, Blumer V, Schrage B, Hanff TC. Hemodynamic management of cardiogenic shock in the intensive care unit. J Heart Lung Transplant 2024; 43:1059-1073. [PMID: 38518863 PMCID: PMC11148863 DOI: 10.1016/j.healun.2024.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Revised: 03/01/2024] [Accepted: 03/11/2024] [Indexed: 03/24/2024] Open
Abstract
Hemodynamic derangements are defining features of cardiogenic shock. Randomized clinical trials have examined the efficacy of various therapeutic interventions, from percutaneous coronary intervention to inotropes and mechanical circulatory support (MCS). However, hemodynamic management in cardiogenic shock has not been well-studied. This State-of-the-Art review will provide a framework for hemodynamic management in cardiogenic shock, including a description of the 4 therapeutic phases from initial 'Rescue' to 'Optimization', 'Stabilization' and 'de-Escalation or Exit therapy' (R-O-S-E), phenotyping and phenotype-guided tailoring of pharmacological and MCS support, to achieve hemodynamic and therapeutic goals. Finally, the premises that form the basis for clinical management and the hypotheses for randomized controlled trials will be discussed, with a view to the future direction of cardiogenic shock.
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Affiliation(s)
- Hoong Sern Lim
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK; University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.
| | - José González-Costello
- Advanced Heart Failure and Heart Transplant Unit, Department of Cardiology, Hospital Universitari de Bellvitge, BIOHEART-Cardiovascular Diseases Research Group, Bellvitge Biomedical Research Institute (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain; Department of Clinical Sciences, School of Medicine, Universitat de Barcelona, Barcelona, Spain; Ciber Cardiovascular (CIBERCV), Instituto Salud Carlos III, Madrid, Spain
| | - Jan Belohlavek
- 2nd Department of Medicine-Department of Cardiovascular Medicine, First Faculty of Medicine, Charles University in Prague and General University Hospital, Prague, Czech Republic; Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
| | - Elric Zweck
- Department of Cardiology, Pulmonology and Vascular Medicine, University Hospital Duesseldorf, Duesseldorf, Germany
| | - Vanessa Blumer
- Inova Schar Heart and Vascular Institute, Inova Fairfax Medical Campus, Falls Church, Virginia
| | - Benedikt Schrage
- University Heart and Vascular Centre Hamburg, German Centre for Cardiovascular Research, Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Thomas C Hanff
- Division of Cardiovascular Medicine, University of Utah School of Medicine, Salt Lake City, Utah
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2
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Nadziakiewicz P, Wajda-Pokrontka M, Przybyłowski P. Post-COVID-19 Era In Heart Transplantation and Its Impact on the Early Postoperative Period After Surgery. Transplant Proc 2024; 56:846-850. [PMID: 38777713 DOI: 10.1016/j.transproceed.2024.03.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2023] [Revised: 01/16/2024] [Accepted: 03/29/2024] [Indexed: 05/25/2024]
Abstract
BACKGROUND End-stage heart failure patients were at increased risk for acquiring COVID-19 infection and progression to severe disease, given multiple health care contacts and underlying health conditions. Understanding the outcomes of such patients will help risk-stratify and guide optimization before heart transplant surgery. The aim of this study was to evaluate the impact of the COVID-19 pandemic on heart transplantation activity and outcomes in the early postoperative period. METHODS Retrospective data analysis of patients undergoing orthotopic heart transplantation in our institution from March 2020 to July 2023. The patient population (N = 208) included 176 (84.6%) men and 32 (15.4%) women. The perioperative data of the pandemic group, March 2020 to February 2022 (N = 151), and the post-pandemic group, March 2022 to July 2023 (N = 57), were compared. RESULTS The number of patients requiring inotropic support increased during the post-COVID-19 era (N = 48 [84.2%], vs N = 72 [47.7%], P < .001). There were no differences in renal complications. Duration of mechanical ventilation was longer in the post-pandemic group (19 hours [14-24] vs 14 hours [9-28], P < .05). CONCLUSIONS The extended duration of mechanical ventilation in the post-pandemic group may be related to the patient's preoperative condition. The number of heart transplant recipients with end-stage heart failure requiring inotropic support increased in the post-COVID-19 era. Although some efforts have been made to reduce the impact of the pandemic, more research is required.
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Affiliation(s)
- Paweł Nadziakiewicz
- Department of Cardiac Anesthesia and Intensive Therapy, Silesian Centre for Heart Diseases, Medical University of Silesia, Zabrze, Poland.
| | - Marta Wajda-Pokrontka
- Department of Cardiac Anesthesia and Intensive Therapy, Silesian Centre for Heart Diseases, Medical University of Silesia, Zabrze, Poland
| | - Piotr Przybyłowski
- Department of Cardiac, Vascular and Endovascular Surgery and Transplantology, Silesian Center for Heart Diseases in Zabrze, Medical University of Silesia, Katowice, Poland
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3
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Venkata Devarakonda B, Kumar S, Tiwari N, Ameta N, Singh S. Ambulatory milrinone therapy as a bridge to heart transplantation. Med J Armed Forces India 2023; 79:726-728. [PMID: 37981937 PMCID: PMC10654362 DOI: 10.1016/j.mjafi.2023.08.014] [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: 08/22/2023] [Accepted: 08/30/2023] [Indexed: 11/21/2023] Open
Abstract
Inotrope therapy for patients with advanced heart failure awaiting a heart transplant or ventricular assist device has been reported to facilitate hospital discharge. We report the case of a 46-year-old man with advanced heart failure (Stage D), initially found unsuitable for a heart transplant due to high pulmonary vascular resistance (PVR) was placed on ambulatory Milrinone therapy leading to significant improvement in PVR. He underwent a successful orthotopic heart transplant.
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Affiliation(s)
- Bhargava Venkata Devarakonda
- Associate Professor (Anaesthesia) & Cardiothoracic Anaesthesiologist, Army Institute of Cardio -Thoracic Sciences (AICTS), Pune, India
| | - Sameer Kumar
- Head & Consultant (Surgery & CT Surgery), Army Institute of Cardio -Thoracic Sciences (AICTS), Pune, India
| | - Nikhil Tiwari
- Consultant (Surgery & CT Surgery), Army Institute of Cardio -Thoracic Sciences (AICTS), Pune, India
| | - Nihar Ameta
- Assistant Professor (Anaesthesia) & Caradiothoracic Anaesthesiologist, Army Institute of Cardio -Thoracic Sciences (AICTS), Pune, India
| | - Saurabh Singh
- Senior Advisor (Surgery & CT Surgery), Army Institute of Cardio -Thoracic Sciences (AICTS), Pune, India
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Gentile P, Masciocco G, Palazzini M, Tedeschi A, Ruzzenenti G, Conti N, D'Angelo L, Foti G, Perna E, Verde A, Ammirati E, Sinagra G, Oliva F, Garascia A. Intravenous continuous home inotropic therapy in advanced heart failure: Insights from an observational retrospective study. Eur J Intern Med 2023; 116:65-71. [PMID: 37393183 DOI: 10.1016/j.ejim.2023.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 05/23/2023] [Accepted: 06/12/2023] [Indexed: 07/03/2023]
Abstract
INTRODUCTION Intravenous inotropic support represents an important therapeutic option in advanced heart failure (HF) as bridge to heart transplantation, bridge to mechanical circulatory support, bridge to candidacy or as palliative therapy. Nevertheless, evidence regarding risks and benefits of its use is lacking. METHODS we conducted a retrospective single center study, analysing the effect of inotropic therapies in an outpatient cohort, evaluating the burden of hospitalizations, the improvement in quality of life, the incidence of adverse events and the evolution of organ damage. RESULTS twenty-seven patients with advanced HF were treated in our Day Hospital service from 2014 to 2021. Nine patients were treated as bridge to heart transplant while eighteen as palliation. Comparing data regarding the year before and after the beginning of inotropic infusion, we observed a reduction of hospitalization (46 vs 25, p<0,001), an improvement of natriuretic peptides, renal and hepatic function since the first month (p<0,001) and a better quality of life in 53% of the population treated. Two hospitalizations for arrhythmias and seven hospitalizations for catheter-related complications were registered. CONCLUSIONS in a selected population of advanced HF patients, continuous home inotropic infusion were able to reduce hospitalizations, improving end organ damage and quality of life. We provide a practical guidance on starting and maintaining home inotropic infusion while monitoring a challenging group of patients.
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Affiliation(s)
- Piero Gentile
- De Gasperis Cardio Center and Transplant Center, Niguarda Hospital, Milan, Italy
| | - Gabriella Masciocco
- De Gasperis Cardio Center and Transplant Center, Niguarda Hospital, Milan, Italy.
| | - Matteo Palazzini
- De Gasperis Cardio Center and Transplant Center, Niguarda Hospital, Milan, Italy
| | - Andrea Tedeschi
- De Gasperis Cardio Center and Transplant Center, Niguarda Hospital, Milan, Italy
| | - Giacomo Ruzzenenti
- De Gasperis Cardio Center and Transplant Center, Niguarda Hospital, Milan, Italy; Department of Health Sciences, University of Milano-Bicocca, Monza, Italy
| | - Nicolina Conti
- De Gasperis Cardio Center and Transplant Center, Niguarda Hospital, Milan, Italy
| | - Luciana D'Angelo
- De Gasperis Cardio Center and Transplant Center, Niguarda Hospital, Milan, Italy
| | - Grazia Foti
- De Gasperis Cardio Center and Transplant Center, Niguarda Hospital, Milan, Italy
| | - Enrico Perna
- De Gasperis Cardio Center and Transplant Center, Niguarda Hospital, Milan, Italy
| | - Alessandro Verde
- De Gasperis Cardio Center and Transplant Center, Niguarda Hospital, Milan, Italy
| | - Enrico Ammirati
- De Gasperis Cardio Center and Transplant Center, Niguarda Hospital, Milan, Italy
| | - Gianfranco Sinagra
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI) and University of Trieste, Trieste, Italy
| | - Fabrizio Oliva
- De Gasperis Cardio Center and Transplant Center, Niguarda Hospital, Milan, Italy
| | - Andrea Garascia
- De Gasperis Cardio Center and Transplant Center, Niguarda Hospital, Milan, Italy
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Mehra MR, Nayak A, Desai AS. Life-Prolonging Benefits of LVAD Therapy in Advanced Heart Failure: A Clinician's Action and Communication Aid. JACC. HEART FAILURE 2023; 11:1011-1017. [PMID: 37226447 DOI: 10.1016/j.jchf.2023.05.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Revised: 04/17/2023] [Accepted: 05/17/2023] [Indexed: 05/26/2023]
Affiliation(s)
- Mandeep R Mehra
- Center for Advanced Heart Disease, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA.
| | - Aditi Nayak
- Center for Advanced Heart Disease, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Akshay S Desai
- Center for Advanced Heart Disease, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
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Carroll AM, Farr M, Russell SD, Schlendorf KH, Truby LK, Gilotra NA, Vader JM, Patel CB, DeVore AD. Beyond Stage C: Considerations in the Management of Patients with Heart Failure Progression and Gaps in Evidence. J Card Fail 2023; 29:818-831. [PMID: 36958390 DOI: 10.1016/j.cardfail.2023.02.015] [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: 09/09/2022] [Revised: 02/07/2023] [Accepted: 02/24/2023] [Indexed: 03/25/2023]
Abstract
Despite treatment with contemporary medical therapies for chronic heart failure (HF), there has been an increase in the prevalence of patients progressing to more advanced disease. Patients progressing to and living at the interface of severe Stage C and Stage D HF are underrepresented in clinical trials, and there is a lack of high-quality evidence to guide clinical decision making. For patients with a severe HF phenotype, the medical therapies used for patients with a less advanced stage of illness are often no longer tolerated nor provide adequate clinical stability. The limited data on these patients highlights the need to increase formal research characterizing this high-risk population. This review summarizes existing clinical trial data on and incorporates our considerations for approaches to the medical management of patients advanced "beyond Stage C" HF.
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Affiliation(s)
- Aubrie M Carroll
- Department of Medicine, Division of Cardiology, Duke University Medical Center, Durham, NC, USA
| | - Maryjane Farr
- Department of Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Stuart D Russell
- Department of Medicine, Division of Cardiology, Duke University Medical Center, Durham, NC, USA
| | - Kelly H Schlendorf
- Department of Medicine, Division of Cardiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Lauren K Truby
- Department of Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Nisha A Gilotra
- Department of Medicine, Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Justin M Vader
- Department of Medicine, Division of Cardiology, Washington University, St Louis, MO, USA
| | - Chetan B Patel
- Department of Medicine, Division of Cardiology, Duke University Medical Center, Durham, NC, USA
| | - Adam D DeVore
- Department of Medicine, Division of Cardiology, Duke University Medical Center, Durham, NC, USA.
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Viéitez Flórez JM, Hernández Pérez FJ, Mitroi C, Lozano Jiménez S, Gómez Bueno M, Segovia Cubero J. Usefulness of ambulatory milrinone perfusion in a cohort of advanced heart failure patients. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2023; 76:386-388. [PMID: 36716994 DOI: 10.1016/j.rec.2022.10.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Accepted: 10/13/2022] [Indexed: 01/30/2023]
Affiliation(s)
- José María Viéitez Flórez
- Unidad de Insuficiencia Cardiaca Avanzada y Trasplante Cardiaco, Hospital Universitario Puerta de Hierro-Majadahonda, Majadahonda, Madrid, Spain.
| | - Francisco José Hernández Pérez
- Unidad de Insuficiencia Cardiaca Avanzada y Trasplante Cardiaco, Hospital Universitario Puerta de Hierro-Majadahonda, Majadahonda, Madrid, Spain
| | - Cristina Mitroi
- Unidad de Insuficiencia Cardiaca Avanzada y Trasplante Cardiaco, Hospital Universitario Puerta de Hierro-Majadahonda, Majadahonda, Madrid, Spain
| | - Sara Lozano Jiménez
- Unidad de Insuficiencia Cardiaca Avanzada y Trasplante Cardiaco, Hospital Universitario Puerta de Hierro-Majadahonda, Majadahonda, Madrid, Spain
| | - Manuel Gómez Bueno
- Unidad de Insuficiencia Cardiaca Avanzada y Trasplante Cardiaco, Hospital Universitario Puerta de Hierro-Majadahonda, Majadahonda, Madrid, Spain
| | - Javier Segovia Cubero
- Unidad de Insuficiencia Cardiaca Avanzada y Trasplante Cardiaco, Hospital Universitario Puerta de Hierro-Majadahonda, Majadahonda, Madrid, Spain
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8
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Sami F, Acharya P, Noonan G, Maurides S, Al-Masry AA, Bajwa S, Parimi N, Boda I, Tran C, Goyal A, Mastoris I, Dalia T, Sauer A, Bakel AVAN, Shah Z. Palliative Inotropes in Advanced Heart Failure: Comparing Outcomes Between Milrinone and Dobutamine. J Card Fail 2022; 28:1683-1691. [PMID: 36122816 DOI: 10.1016/j.cardfail.2022.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2022] [Revised: 08/17/2022] [Accepted: 08/21/2022] [Indexed: 10/14/2022]
Abstract
BACKGROUND We sought to describe and compare outcomes among advanced patients with heart failure (not candidates for orthotopic heart transplant/left ventricular assist device) on long-term milrinone or dobutamine, which are not well-studied in the contemporary era. METHODS AND RESULTS We included adults with refractory stage D heart failure who were not candidates for orthotopic heart transplant or left ventricular assist device and discharged on palliative dobutamine or milrinone. The primary outcome was 1-year survival. A 6-month predictor of survival analysis was conducted. A total of 248 patients (133 on milrinone, 115 on dobutamine) were included. There were no differences in baseline comorbidities between milrinone and dobutamine cohorts, except for the prevalence of chronic kidney disease, which was higher in the dobutamine group. On discharge, the proportion of patients on beta-blockers and mineralocorticoid antagonists was higher in milrinone group. Overall, the 1-year mortality rate was 70%. The dobutamine cohort had a significantly higher 1-year mortality rate (84% vs 58%, P <0.001). The type of inotrope did not predict survival at 6 months when adjusted for discharge medications and comorbidities. Beta-blockers and angiotensin-converting enzyme/angiotensin receptor blocker/angiotensin receptor neprilysin inhibitor continued at discharge predicted survival at 6 months. CONCLUSIONS The 1-year mortality from palliative inotropes remains high. Compared with dobutamine, use of milrinone was associated with improved survival owing to better optimization of guideline-directed medical therapy, primarily beta-blocker therapy.
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Affiliation(s)
- Farhad Sami
- Department of Internal Medicine, University of Kansas Medical Center, Kansas City, Kansas; University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Prakash Acharya
- Department of Cardiovascular Medicine, University of Kansas Medical Center, Kansas City, Kansas
| | - Grace Noonan
- Medical Student, University of Kansas Medical Center, Kansas City, Kansas
| | - Steven Maurides
- Division of Cardiology, Medical University of South Carolina, Charleston, South Carolina
| | - Anas Abudan Al-Masry
- Department of Internal Medicine, University of Kansas Medical Center, Kansas City, Kansas; University of Arizona, Phoenix, Arizona
| | - Suhaib Bajwa
- Medical Student, University of Kansas Medical Center, Kansas City, Kansas
| | - Nikhil Parimi
- Department of Internal Medicine, University of Kansas Medical Center, Kansas City, Kansas
| | - Ilham Boda
- Department of Internal Medicine, University of Kansas Medical Center, Kansas City, Kansas
| | - Christina Tran
- Medical Student, University of Kansas Medical Center, Kansas City, Kansas
| | - Amandeep Goyal
- Department of Cardiovascular Medicine, University of Kansas Medical Center, Kansas City, Kansas
| | - Ioannis Mastoris
- Department of Cardiovascular Medicine, University of Kansas Medical Center, Kansas City, Kansas
| | - Tarun Dalia
- Department of Cardiovascular Medicine, University of Kansas Medical Center, Kansas City, Kansas
| | - Andrew Sauer
- Department of Cardiovascular Medicine, University of Kansas Medical Center, Kansas City, Kansas
| | - Adrian VAN Bakel
- Division of Cardiology, Medical University of South Carolina, Charleston, South Carolina
| | - Zubair Shah
- Department of Cardiovascular Medicine, University of Kansas Medical Center, Kansas City, Kansas.
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Viéitez Flórez JM, Hernández Pérez FJ, Mitroi C, Jiménez Lozano S, Gómez Bueno M, Segovia Cubero J. Utilidad de la perfusión ambulatoria de milrinona en una cohorte de pacientes con insuficiencia cardiaca avanzada. Rev Esp Cardiol 2022. [DOI: 10.1016/j.recesp.2022.10.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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10
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Cheema B, Mutharasan RK, Sharma A, Jacobs M, Powers K, Lehrer S, Wehbe FH, Ronald J, Pifer L, Rich JD, Ghafourian K, Tibrewala A, McCarthy P, Luo Y, Pham DT, Wilcox JE, Ahmad FS. Augmented Intelligence to Identify Patients With Advanced Heart Failure in an Integrated Health System. JACC. ADVANCES 2022; 1:100123. [PMID: 36643021 PMCID: PMC9838119 DOI: 10.1016/j.jacadv.2022.100123] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 09/05/2022] [Accepted: 09/06/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Timely referral for specialist evaluation in patients with advanced heart failure (HF) is a Class 1 recommendation. However, the transition from stage C HF to advanced or stage D HF often goes undetected in routine care, resulting in delayed referral and higher mortality rates. OBJECTIVES The authors sought to develop an augmented intelligence-enabled workflow using machine learning to identify patients with stage D HF and streamline referral. METHODS We extracted data on HF patients with encounters from January 1, 2007, to November 30, 2020, from a HF registry within a regional, integrated health system. We created an ensemble machine learning model to predict stage C or stage D HF and integrated the results within the electronic health record. RESULTS In a retrospective data set of 14,846 patients, the model had a good positive predictive value (60%) and low sensitivity (25%) for identifying stage D HF in a 100-person, physician-reviewed, holdout test set. During prospective implementation of the workflow from April 1, 2021, to February 15, 2022, 416 patients were reviewed by a clinical coordinator, with agreement between the model and the coordinator in 50.3% of stage D predictions. Twenty-four patients have been scheduled for evaluation in a HF clinic, 4 patients started an evaluation for advanced therapies, and 1 patient received a left ventricular assist device. CONCLUSIONS An augmented intelligence-enabled workflow was integrated into clinical operations to identify patients with advanced HF. Endeavors such as this require a multidisciplinary team with experience in design thinking, informatics, quality improvement, operations, and health information technology, as well as dedicated resources to monitor and improve performance over time.
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Affiliation(s)
- Baljash Cheema
- Bluhm Cardiovascular Institute Center for Artificial Intelligence, Northwestern Medicine, Chicago, Illinois, USA
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - R. Kannan Mutharasan
- Bluhm Cardiovascular Institute Center for Artificial Intelligence, Northwestern Medicine, Chicago, Illinois, USA
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Aditya Sharma
- Bluhm Cardiovascular Institute Center for Artificial Intelligence, Northwestern Medicine, Chicago, Illinois, USA
- Northwestern Medicine, Chicago, Illinois, USA
| | - Maia Jacobs
- Department of Computer Science, Northwestern University McCormick School of Engineering, Evanston, Illinois, USA
| | | | | | - Firas H. Wehbe
- Bluhm Cardiovascular Institute Center for Artificial Intelligence, Northwestern Medicine, Chicago, Illinois, USA
- Division of Cardiac Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | | | | | - Jonathan D. Rich
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Kambiz Ghafourian
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Anjan Tibrewala
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Patrick McCarthy
- Bluhm Cardiovascular Institute Center for Artificial Intelligence, Northwestern Medicine, Chicago, Illinois, USA
- Division of Cardiac Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Yuan Luo
- Division of Health and Biomedical Informatics, Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Duc T. Pham
- Division of Cardiac Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Jane E. Wilcox
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Faraz S. Ahmad
- Bluhm Cardiovascular Institute Center for Artificial Intelligence, Northwestern Medicine, Chicago, Illinois, USA
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Division of Health and Biomedical Informatics, Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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11
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Eaton RE, Kissling KT, Haas GJ, McLaughlin EM, Pickworth KK. Rehospitalization of Patients with Advanced Heart Failure Receiving Continuous, Palliative Dobutamine or Milrinone. Am J Cardiol 2022; 184:80-89. [PMID: 36167736 DOI: 10.1016/j.amjcard.2022.08.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Revised: 07/14/2022] [Accepted: 08/17/2022] [Indexed: 11/01/2022]
Abstract
This study aims to determine the incidence of all-cause hospitalization in patients with advanced heart failure (AHF) receiving ambulatory continuous, intravenous dobutamine versus milrinone for palliative intent. Despite medical optimization, patients with AHF develop refractory symptoms, resulting in frequent hospitalizations. Previous trials precede modern care standards. Data regarding inotrope choice in palliation are limited. This retrospective analysis included 222 patients with AHF and reduced left ventricular ejection fraction discharged on palliative dobutamine (n = 135) or milrinone (n = 87). The primary outcome was incidence of all-cause rehospitalization compared by treatment type. Demographics between groups were similar. In the milrinone arm, more patients were discharged on β blockers (62% vs 22%; p <0.001); fewer patients were discharged to hospice (6% vs 30%). More patients in the milrinone arm than in the dobutamine arm were rehospitalized within 180 days (80% vs 59%; p = 0.002); when patients discharged to hospice were excluded, this difference was no longer significant (83% vs 74%; p = 0.14). Overall mortality was lower in the milrinone arm (63% vs 80%; p = 0.006); survival was longer (median: 228 vs 52 days; p <0.001). Patients receiving milrinone spent more days alive and out of the hospital at 90 days after discharge (70 vs 37 days; p <0.001). In conclusion, in patients with AHF receiving palliative inotropes, there was no difference in rehospitalization when excluding patients discharged to hospice. Milrinone use was associated with decreased mortality and longer survival. Agent selection must closely align with the patient's disease trajectory.
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Affiliation(s)
- Rachael E Eaton
- Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, Ohio.
| | - Kevin T Kissling
- Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Garrie J Haas
- Department of Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Eric M McLaughlin
- Department of Biostatistics, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Kerry K Pickworth
- Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, Ohio
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12
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Lee JH, Hwang KK. End-of-Life Care for End-stage Heart Failure Patients. Korean Circ J 2022; 52:659-679. [PMID: 36097835 PMCID: PMC9470494 DOI: 10.4070/kcj.2022.0211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 08/11/2022] [Indexed: 11/11/2022] Open
Abstract
Although recent heart failure (HF) guidelines highlight integrative palliative care, including end-of-life (EOL), appropriate discussing EOL issues can be challenging due to possibility of unexpected deterioration throughout HF trajectory. Open communication and discussions with multidisciplinary team are important for setting patient and family expectations and establishing mutually agreed goals of care based firmly on the patient’s ‘human dignity’ and ‘right to self-determination.’ Especially when quality-of-life outweighs expanding quantity-of-life, transition to EOL care should be considered. Advanced care planning including resuscitation, device deactivation, site for last days, and bereavement support should focus on ensuring a good death, and be reviewed regularly. Efforts to improve end-of-life (EOL) care have generally been focused on cancer patients, but high-quality EOL care is also important for patients with other serious medical illnesses including heart failure (HF). Recent HF guidelines offer more clinical considerations for palliative care including EOL care than ever before. Because HF patients can experience rapid, unexpected clinical deterioration or sudden death throughout the disease trajectory, choosing an appropriate time to discuss issues such as advance directives or hospice can be challenging in real clinical situations. Therefore, EOL issues should be discussed early. Conversations are important for understanding patient and family expectations and developing mutually agreed goals of care. In particular, high-quality communication with patient and family through a multidisciplinary team is necessary to define patient-centered goals of care and establish treatment based on goals. Control of symptoms such as dyspnea, pain, anxiety/depression, fatigue, nausea, anorexia, and altered mental status throughout the dying process is an important issue that is often overlooked. When quality-of-life outweighs expanding quantity-of-life, the transition to EOL care should be considered. Advanced care planning including resuscitation (i.e., do-not resuscitate order), device deactivation, site for last days and bereavement support for the family should focus on ensuring a good death and be reviewed regularly. It is essential to ensure that treatment for all HF patients incorporates discussions about the overall goals of care and individual patient preferences at both the EOL and sudden changes in health status. In this review, we focus on EOL care for end-stage HF patients.
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Affiliation(s)
- Ju-Hee Lee
- Department of Internal Medicine, Chungbuk National University College of Medicine, Cheongju, Korea.,Division of Cardiology, Department of Internal Medicine, Chungbuk National University Hospital, Cheongju, Korea
| | - Kyung-Kuk Hwang
- Department of Internal Medicine, Chungbuk National University College of Medicine, Cheongju, Korea.,Division of Cardiology, Department of Internal Medicine, Chungbuk National University Hospital, Cheongju, Korea.
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Baudry G, Coutance G, Dorent R, Bauer F, Blanchart K, Boignard A, Chabanne C, Delmas C, D'Ostrevy N, Epailly E, Gariboldi V, Gaudard P, Goéminne C, Grosjean S, Guihaire J, Guillemain R, Mattei M, Nubret K, Pattier S, Pozzi M, Rossignol P, Vermes E, Sebbag L, Girerd N. Prognosis value of Forrester's classification in advanced heart failure patients awaiting heart transplantation. ESC Heart Fail 2022; 9:3287-3297. [PMID: 35801277 DOI: 10.1002/ehf2.14037] [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: 02/07/2022] [Revised: 05/04/2022] [Accepted: 06/03/2022] [Indexed: 11/09/2022] Open
Abstract
AIMS The value of Forrester's perfusion/congestion profiles assessed by invasive catheter evaluation in non-inotrope advanced heart failure patients listed for heart transplant (HT) is unclear. We aimed to assess the value of haemodynamic evaluation according to Forrester's profiles to predict events on the HT waitlist. METHODS AND RESULTS All non-inotrope patients (n = 837, 79% ambulatory at listing) registered on the French national HT waiting list between 1 January 2013 and 31 December 2019 with right heart catheterization (RHC) were included. The primary outcome was a combined criteria of waitlist death, delisting for aggravation, urgent HT or left ventricular assist device implantation. Secondary outcome was waitlist death. The 'warm-dry', 'cold-dry', 'warm-wet', and 'cold-wet' profiles represented 27%, 18%, 27%, and 28% of patients, respectively. At 12 months, the respective rates of primary outcome were 15%, 17%, 25%, and 29% (P = 0.008). Taking the 'warm-dry' category as reference, a significant increase in the risk of primary outcome was observed only in the 'wet' categories, irrespectively of 'warm/cold' status: hazard ratios, 1.50; 1.06-2.13; P = 0.024 in 'warm-wet' and 1.77; 1. 25-2.49; P = 0.001 in 'cold-wet'. CONCLUSIONS Haemodynamic assessment of advanced HF patients using perfusion/congestion profiles predicts the risk of the combine endpoint of waitlist death, delisting for aggravation, urgent heart transplantation, or left ventricular assist device implantation. 'Wet' patients had the worst prognosis, independently of perfusion status, thus placing special emphasis on the cardinal prominence of persistent congestion in advanced HF.
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Affiliation(s)
- Guillaume Baudry
- Department of heart failure and transplantation, Hôpital Cardiovasculaire Louis Pradel, Hospices Civils de Lyon, 69500, Bron, France.,Centre d'Investigations Cliniques Plurithématique 1433, INSERM DCAC, CHRU de Nancy, F-CRIN INI-CRCT, Université de Lorraine, 54500, Vandoeuvre-lès-Nancy, Nancy, France
| | - Guillaume Coutance
- Department of Cardiac and Thoracic Surgery, Cardiology Institute, Pitié Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP). Sorbonne University Medical School, Paris, France
| | - Richard Dorent
- Department of Cardiac Surgery, CHU Bichat-Claude Bernard, AP-HP, Université Paris VII, 75877, Paris, France
| | - Fabrice Bauer
- Department of Cardiology and Cardiovascular Surgery, Hospital Charles Nicolle, Rouen, France
| | - Katrien Blanchart
- Department of Cardiology and Cardiac Surgery, University Hospital of Caen, University of Caen, Caen, France
| | - Aude Boignard
- Department of Cardiology and Cardiovascular Surgery, CHU Michallon, Grenoble, France
| | - Céline Chabanne
- Department of Thoracic and Cardiovascular Surgery, CHU Pontchaillou, Inserm U1099, 35000, Rennes, France
| | - Clément Delmas
- Department of Cardiology, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - Nicolas D'Ostrevy
- Cardiology and Cardiac Surgery Department, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Eric Epailly
- Department of Cardiology and Cardiovascular Surgery, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Vlad Gariboldi
- Department of Cardiac Surgery, La Timone Hospital, Marseille, France
| | - Philippe Gaudard
- Department of Cardiac Surgery, Anesthesiology and Critical Care Medicine, Arnaud de Villeneuve Hospital, CHRU Montpellier, Montpellier, France
| | - Céline Goéminne
- Department of Cardiac Surgery, CHU Lille, Institut Coeur Poumons, Lille, France
| | - Sandrine Grosjean
- Department of Cardiology and Cardiac Surgery, University Hospital of Dijon, Dijon, France
| | - Julien Guihaire
- Department of Cardiothoracic Surgery, Marie Lannelongue Hospital, University of Paris Sud, Inserm U999 [Pulmonary Hypertension: Pathophysiology and Novel Therapies (PAH)], 92350, Le Plessis Robinson, France
| | - Romain Guillemain
- Cardiology and Cardiac Surgery Department, European Georges Pompidou Hospital, Paris, France
| | - Mathieu Mattei
- Department of Cardiology and Cardiac Surgery, CHU de Nancy, Hopital de Brabois, Nancy, France
| | - Karine Nubret
- Department of Thoracic and Cardiovascular Surgery, Hôpital Cardiologique du Haut-Lévêque, Université Bordeaux II, Bordeaux, France
| | - Sabine Pattier
- Department of Cardiology and Heart Transplantation Unit, CHU de Nantes, Nantes, France
| | - Matteo Pozzi
- Department of heart failure and transplantation, Hôpital Cardiovasculaire Louis Pradel, Hospices Civils de Lyon, 69500, Bron, France
| | - Patrick Rossignol
- Centre d'Investigations Cliniques Plurithématique 1433, INSERM DCAC, CHRU de Nancy, F-CRIN INI-CRCT, Université de Lorraine, 54500, Vandoeuvre-lès-Nancy, Nancy, France
| | - Emmanuelle Vermes
- Cardiothoracic Surgery Department, Tours University Hospital, Tours, France
| | - Laurent Sebbag
- Department of heart failure and transplantation, Hôpital Cardiovasculaire Louis Pradel, Hospices Civils de Lyon, 69500, Bron, France
| | - Nicolas Girerd
- Centre d'Investigations Cliniques Plurithématique 1433, INSERM DCAC, CHRU de Nancy, F-CRIN INI-CRCT, Université de Lorraine, 54500, Vandoeuvre-lès-Nancy, Nancy, France
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Heidenreich PA, Bozkurt B, Aguilar D, Allen LA, Byun JJ, Colvin MM, Deswal A, Drazner MH, Dunlay SM, Evers LR, Fang JC, Fedson SE, Fonarow GC, Hayek SS, Hernandez AF, Khazanie P, Kittleson MM, Lee CS, Link MS, Milano CA, Nnacheta LC, Sandhu AT, Stevenson LW, Vardeny O, Vest AR, Yancy CW. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2022; 145:e895-e1032. [PMID: 35363499 DOI: 10.1161/cir.0000000000001063] [Citation(s) in RCA: 679] [Impact Index Per Article: 339.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
AIM The "2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure" replaces the "2013 ACCF/AHA Guideline for the Management of Heart Failure" and the "2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure." The 2022 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with heart failure. METHODS A comprehensive literature search was conducted from May 2020 to December 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (PubMed), EMBASE, the Cochrane Collaboration, the Agency for Healthcare Research and Quality, and other relevant databases. Additional relevant clinical trials and research studies, published through September 2021, were also considered. This guideline was harmonized with other American Heart Association/American College of Cardiology guidelines published through December 2021. Structure: Heart failure remains a leading cause of morbidity and mortality globally. The 2022 heart failure guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with heart failure, with the intent to improve quality of care and align with patients' interests. Many recommendations from the earlier heart failure guidelines have been updated with new evidence, and new recommendations have been created when supported by published data. Value statements are provided for certain treatments with high-quality published economic analyses.
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Affiliation(s)
| | | | | | | | | | | | - Anita Deswal
- ACC/AHA Joint Committee on Clinical Practice Guidelines Liaison
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15
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Heidenreich PA, Bozkurt B, Aguilar D, Allen LA, Byun JJ, Colvin MM, Deswal A, Drazner MH, Dunlay SM, Evers LR, Fang JC, Fedson SE, Fonarow GC, Hayek SS, Hernandez AF, Khazanie P, Kittleson MM, Lee CS, Link MS, Milano CA, Nnacheta LC, Sandhu AT, Stevenson LW, Vardeny O, Vest AR, Yancy CW. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure. J Am Coll Cardiol 2022; 79:e263-e421. [PMID: 35379503 DOI: 10.1016/j.jacc.2021.12.012] [Citation(s) in RCA: 775] [Impact Index Per Article: 387.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
AIM The "2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure" replaces the "2013 ACCF/AHA Guideline for the Management of Heart Failure" and the "2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure." The 2022 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with heart failure. METHODS A comprehensive literature search was conducted from May 2020 to December 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (PubMed), EMBASE, the Cochrane Collaboration, the Agency for Healthcare Research and Quality, and other relevant databases. Additional relevant clinical trials and research studies, published through September 2021, were also considered. This guideline was harmonized with other American Heart Association/American College of Cardiology guidelines published through December 2021. STRUCTURE Heart failure remains a leading cause of morbidity and mortality globally. The 2022 heart failure guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with heart failure, with the intent to improve quality of care and align with patients' interests. Many recommendations from the earlier heart failure guidelines have been updated with new evidence, and new recommendations have been created when supported by published data. Value statements are provided for certain treatments with high-quality published economic analyses.
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16
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Grazette L, Tran JS, Zawadzki NK, Zawadzki RS, McLeod JM, Fong MW, Wilson ML, Havakuk O, Hay JW. Geographic variation in the use of continuous outpatient inotrope infusion therapy and beta blockers. IJC HEART & VASCULATURE 2022; 39:100948. [PMID: 35242996 PMCID: PMC8857491 DOI: 10.1016/j.ijcha.2021.100948] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 12/11/2021] [Accepted: 12/25/2021] [Indexed: 01/13/2023]
Abstract
Background Continuous outpatient inotrope infusion therapy (COIIT) can be used as palliative or interim treatment in patients with advanced heart failure (AHF). Despite widespread use, there is a relative lack of data informing best practices. This study aimed to examine whether patterns of COIIT use differed by region and to explore whether observed differences influenced clinical outcomes. Methods Retrospective study of AHF patients receiving COIIT from May 2009 through June 2016. The primary outcome was regional difference, the secondary outcome was persistence (duration) on therapy. Cox proportional hazards model was used to calculate hazard ratios for treatment regimens. Results There were 3,286 patients, mean (SD) age 61.9 (14.4) years and 74.0% (2,433) male. Inotrope selection and beta blocker use varied by region by chi square (χ2 (21) = 166.9, p < 0.001). Persistence was greater on milrinone compared to dobutamine (HR (for discontinuation) 0.54, CI 0.41–0.70, p < 0.001). Concurrent beta-blocker was associated with greater persistence for patients receiving milrinone (HR 0.13, CI 0.08–0.20, p < 0.001) and dobutamine (HR 0.36, CI 0.18–0.71, p < 0.001). Conclusions Patterns of COIIT use varied by region, and variations in use were associated with differences in clinical outcomes.
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Affiliation(s)
- Luanda Grazette
- Cardiovascular Division, University of Miami Miller School of Medicine, Miami, FL, United States
- Corresponding author at: University of Miami Miller School of Medicine, Cardiovascular Division, 1120 NW 14th St., Miami, FL 33136, United States.
| | - Jeffrey S. Tran
- Sarver Heart Center, University of Arizona, Tucson, AZ, United States
| | - Nadine K. Zawadzki
- Department of Pharmaceutical and Health Economics, USC School of Pharmacy, Los Angeles, CA, United States
- Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles, CA, United States
| | - Roy S. Zawadzki
- Department of Statistics, Donald Bren School of Information and Computer Science, University of California, Irvine, CA, United States
| | - Jennifer M. McLeod
- Division of Cardiology, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY, United States
| | - Michael W. Fong
- Sarver Heart Center, University of Arizona, Tucson, AZ, United States
| | - Melissa L. Wilson
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Ofer Havakuk
- Department of Cardiology, Tel Aviv Medical Center, affiliated to the Tel Aviv University, Tel Aviv, Israel
| | - Joel W. Hay
- Department of Pharmaceutical and Health Economics, USC School of Pharmacy, Los Angeles, CA, United States
- Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles, CA, United States
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17
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Almeida DRD, Pereira-Barretto AC, Forestiero FJ, Nakamuta JS, Bichels A. The Medical Burden of Heart Failure: A Comparative Delineation with Cancer in Brazil. INTERNATIONAL JOURNAL OF CARDIOVASCULAR SCIENCES 2022. [DOI: 10.36660/ijcs.20200382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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18
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Laufer‐Perl M, Sadon S, Zahler D, Milwidsky A, Sadeh B, Sapir O, Granot Y, Korotetski L, Ketchker L, Rosh M, Banai S, Havakuk O. Repetitive milrinone therapy in ambulatory advanced heart failure patients. Clin Cardiol 2022; 45:488-494. [PMID: 35243658 PMCID: PMC9045071 DOI: 10.1002/clc.23802] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Revised: 02/13/2022] [Accepted: 02/15/2022] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Advanced heart failure (HF) patients usually poorly tolerate guideline-directed HF medical therapy (GDMT) and suffer high rates of morbidity and mortality. The use of continuous inotropes in the outpatient settings is hampered by previous data showing excess morbidity. We aimed to assess the safety and efficacy of repetitive, intermittent, short-term intravenous milrinone therapy in advanced HF patients with an intention to introduce and up-titrate GDMT and improve functional class. HYPOTHESIS Repetitive, intermittent milrinone therapy may assist with the stabilization of advanced HF patients. METHODS Advanced HF patients treated with beta-blockers and implanted with defibrillators were initiated with repetitive, intermittent short-term intravenous milrinone therapy at our HF outpatient unit. Patients were prospectively followed with defibrillator interrogation, functional class assessment, B-natriuretic peptide (BNP) levels, and echocardiography parameters. RESULTS The cohort included 24 patients with a mean 330 ± 240 days of milrinone therapy exposure. Mean age was 73 ± 6 years with male predominance (96%). Following milrinone therapy, median BNP levels decreased significantly (882 [286-3768] to 631 [278-1378] pg/ml, p = .017) with a significant reduction in the number of patients with New York Heart Association (NYHA) Class III and IV (p = .012, 0.013) and an increase in number of patients on GDMT. Importantly, the number of total sustained ventricular tachycardia events and HF hospitalizations did not change. CONCLUSIONS In this small cohort of advanced HF, repetitive, intermittent, short-term milrinone therapy was found to be safe and potentially efficacious.
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Affiliation(s)
- Michal Laufer‐Perl
- Cardiology Division, Tel Aviv Sourasky Medical Centeraffiliated to Tel Aviv UniversityTel AvivIsrael
| | - Sapir Sadon
- Cardiology Division, Tel Aviv Sourasky Medical Centeraffiliated to Tel Aviv UniversityTel AvivIsrael
| | - David Zahler
- Cardiology Division, Tel Aviv Sourasky Medical Centeraffiliated to Tel Aviv UniversityTel AvivIsrael
| | - Assi Milwidsky
- Cardiology Division, Tel Aviv Sourasky Medical Centeraffiliated to Tel Aviv UniversityTel AvivIsrael
| | - Ben Sadeh
- Cardiology Division, Tel Aviv Sourasky Medical Centeraffiliated to Tel Aviv UniversityTel AvivIsrael
| | - Orly Sapir
- Cardiology Division, Tel Aviv Sourasky Medical Centeraffiliated to Tel Aviv UniversityTel AvivIsrael
| | - Yoav Granot
- Cardiology Division, Tel Aviv Sourasky Medical Centeraffiliated to Tel Aviv UniversityTel AvivIsrael
| | - Liuba Korotetski
- Cardiology Division, Tel Aviv Sourasky Medical Centeraffiliated to Tel Aviv UniversityTel AvivIsrael
| | - Liora Ketchker
- Cardiology Division, Tel Aviv Sourasky Medical Centeraffiliated to Tel Aviv UniversityTel AvivIsrael
| | - Maayan Rosh
- Cardiology Division, Tel Aviv Sourasky Medical Centeraffiliated to Tel Aviv UniversityTel AvivIsrael
| | - Shmuel Banai
- Cardiology Division, Tel Aviv Sourasky Medical Centeraffiliated to Tel Aviv UniversityTel AvivIsrael
| | - Ofer Havakuk
- Cardiology Division, Tel Aviv Sourasky Medical Centeraffiliated to Tel Aviv UniversityTel AvivIsrael
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Wolfe A, Watt CL, Downar J, Bush SH. Use and Discontinuation of Milrinone for Advanced Heart Failure in an Academic Palliative Care Unit: A Case Report and Discussion of Recommendations. J Pain Palliat Care Pharmacother 2022; 36:24-33. [PMID: 35234559 DOI: 10.1080/15360288.2022.2027058] [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: 10/19/2022]
Abstract
The use of intravenous inotropic medications in advanced heart failure (HF) has been shown to improve symptoms and decrease hospitalizations, prompting support for their use as a palliative measure for symptom management. Recommendations regarding inotrope management and method of discontinuation at the end of life are not specifically detailed in the literature and current guidelines. This case report describes the use of milrinone in a patient with advanced HF during the terminal phase of illness in a non-monitored palliative care unit setting, including dose reduction and discontinuation of milrinone. Increased patient anxiety during the weaning process was managed with midazolam. The provision of individualized milrinone therapy in non-monitored palliative care settings is feasible and well-tolerated using the presented detailed recommendations for its use and administration, monitoring, dose reduction and discontinuation and proactive symptom management at the end of life. Further research is needed for the optimal management of terminally ill patients with advanced HF.Supplemental data for this article is available online at here. show.
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McPherson A, Nguyen C, Groninger H, Anderson KM, Henderson P, Rao A. Continuous Intravenous Inotropic Support for Advanced Heart Failure: Palliative Considerations. J Pain Palliat Care Pharmacother 2022; 36:59-67. [PMID: 35319327 DOI: 10.1080/15360288.2022.2050456] [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: 10/18/2022]
Abstract
The global prevalence of heart failure (HF) is increasing. Advancements in guideline-directed medical and device therapy have resulted in improved survival. Thus, there are more patients living - and living longer - with advanced HF. Only a small proportion of these patients are deemed appropriate for advanced surgical intervention (mechanical circulatory support or heart transplantation), and even if offered, some may decline such interventions if not aligned with their overall goals and values. Therefore, a growing number of patients with advanced HF receive chronic intravenous inotropic support (CIIS) for palliation of symptoms. Despite increased use, clinical evidence supporting use of palliative inotropes remains limited. However, available data suggest improvements in functional class, health-related quality of life (HRQoL) indicators, symptom burden, hemodynamic parameters, and possibly rehospitalization. While initial concerns regarding increased mortality have been assuaged in the modern era of guideline-directed medical therapy, palliative inotropes are certainly not without burden. Risks of infection and medication-related adverse effects, need for routine laboratory monitoring, frequent dressing changes, and presence of a reliable caregiver must be carefully considered prior to initiation. This review addresses pharmacology, guideline recommendations, benefits and burdens, considerations related to hospice and end-of-life care, and future directions of CIIS in advanced HF care.
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Abstract
The introduction of multiple new pharmacological agents over the past three decades in the field of heart failure with reduced ejection fraction (HFrEF) has led to reduced rates of mortality and hospitalizations, and consequently the prevalence of HFrEF has increased, and up to 10% of patients progress to more advanced stages, characterized by high rates of mortality, hospitalizations, and poor quality of life. Advanced HFrEF patients often show persistent or progressive signs of severe HF symptoms corresponding to New York Heart Association class III or IV despite being on optimal medical, surgical, and device therapies. However, a subpopulation of patients with advanced HF, those with the most advanced stages of disease, were often insufficiently represented in the major trials demonstrating efficacy and tolerability of the drugs used in HFrEF due to exclusion criteria such as low BP and kidney dysfunction. Consequently, the results of many landmark trials cannot necessarily be transferred to patients with the most advanced stages of HFrEF. Thus, the efficacy and tolerability of guideline-directed medical therapies in patients with the most advanced stages of HFrEF often remain unsettled, and this knowledge is of crucial importance in the planning and timing of consideration for referral for advanced therapies. This review discusses the evidence regarding the use of contemporary drugs in the advanced HFrEF population, covering components such as guideline HFrEF drugs, diuretics, inotropes, and the use of HFrEF drugs in LVAD recipients, and provides suggestions on how to manage guideline-directed therapy in this patient group.
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22
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Levosimendan and continuous outpatient support with inotropes (COSI) in patients with advanced heart failure: a single-centre descriptive study. J Cardiovasc Pharmacol 2021; 79:583-592. [PMID: 34983918 DOI: 10.1097/fjc.0000000000001214] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2021] [Accepted: 12/11/2021] [Indexed: 11/26/2022]
Abstract
ABSTRACT To describe the use of levosimendan in a quaternary referral centre with a dedicated heart failure service and compare its efficacy and safety to continuous outpatient support with inotropes (COSI) among patients with advanced heart failure (AHF) who require bridge to decision (BTD) or bridge to transplant (BTT) therapy. This study was a retrospective, single-centre, descriptive study of patients with AHF who received either a single levosimendan infusion or COSI between 2018 and 2021. A total of 23 patients received a levosimendan infusion, and 14 were commenced on COSI. Three indications for levosimendan were identified - (1) to facilitate weaning of continuous inotropes, (2) to augment diuresis in cardiorenal syndrome, and (3) as first-line therapy for cardiogenic shock in selected patients. Eighty-three percent (19/23) of patients who received levosimendan survived to discharge, and there were few clinically significant adverse events. Overall survival at 12 months among patients who received levosimendan was 74%. No statistically significant difference in survival was observed at 12 months (p = 0.68) or beyond (p = 0.63) between patients that received levosimendan and were discharged with a plan for BTD or BTT, and those that received COSI. Levosimendan is a safe and effective short-term therapy in AHF and offers comparable long-term survival to COSI in patients that require BTD or BTT therapy.
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Wollborn J, Mizuguchi KA, Ulbrich F, Brovman EY. Cardiac Anesthesiologists’ and Intensivists’ Impact on the Treatment of Patients at Advanced Heart Failure Centers. J Cardiothorac Vasc Anesth 2021; 36:1228-1230. [DOI: 10.1053/j.jvca.2021.12.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 12/09/2021] [Indexed: 11/11/2022]
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Lim HS, Shaw S, Carter AW, Jayawardana S, Mossialos E, Mehra MR. A clinical and cost-effectiveness analysis of the HeartMate 3 left ventricular assist device for transplant-ineligible patients: A United Kingdom perspective. J Heart Lung Transplant 2021; 41:174-186. [PMID: 34922821 DOI: 10.1016/j.healun.2021.11.014] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 11/18/2021] [Accepted: 11/19/2021] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND The clinical and cost-effectiveness of left ventricular assist device (LVAD) therapy for patients with advanced heart failure (HF) who are ineligible for heart transplantation is debated in the UK. This study develops an indirect comparison between the fully magnetically levitated HeartMate 3 (HM 3) LVAD and medical therapy (MT) to evaluate expected clinical and cost-effectiveness in the UK National Health Service (NHS) context. METHODS We performed an economic analysis comparing the HM3 pump against the HeartMate II LVAD (MOMENTUM 3), and then another analysis comparing MT with the first- and second-generation HeartMate XVE pump LVAD and HeartMate II LVAD for the same patient population (REMATCH and ROADMAP, respectively). By bridging those 2 analyses, an indirect comparison between HM3 and MT in the form of a network meta-analysis was developed. A literature search was performed to select the most appropriate pair of studies for this purpose. Outcomes were adjusted to produce Kaplan-Meier curves for the cost-effectiveness evaluation by using a decision-analytic model. Data were extrapolated linearly over a 5-year time horizon. Uncertainty and additional scenarios were addressed by one-way and probabilistic sensitivity analysis. Local costs and health utility were used from England, thereby representing the UK context. RESULTS The incremental cost-effectiveness ratio (ICER) for LVAD vs MT in transplant ineligible patients with advanced HF was estimated to be £47,361 per quality-adjusted life year gained, with a 97.1% probability of being cost-effective at £50,000. In a subgroup of patients who are inotropic therapy dependent (INTERMACS 1-3 severity profile), the ICER was £45,616, while for a population with less-ill ambulatory HF (INTERMACS profile 4-7) the ICER changed to £64,051. CONCLUSIONS This study provides evidence that HM3 LVAD therapy in advanced HF patients ineligible for heart transplantation may be cost-effective compared to MT in the NHS UK-England context. The ICER is lowest for patients dependent on inotropic support, but exceeds the willingness to pay threshold of £50,000 in ambulatory noninotropic therapy dependent advanced HF patients.
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Affiliation(s)
- Hoong Sern Lim
- University Hospital Birmingham NHS Foundation Trust, Birmingham, UK
| | - Steven Shaw
- Manchester University NHS Foundation Trust, Manchester, UK
| | | | | | | | - Mandeep R Mehra
- Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston, Massachusetts.
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25
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Wong KL, Ho KLC, Lee OJ, Lun KS, Bhatia I, Tam WYE, Fan YYK, Au WKT. Emerging roles of left ventricular assist device therapy as bridge to transplant in an Asian city with scarce heart transplant donor. J Thorac Dis 2021; 13:5717-5730. [PMID: 34795921 PMCID: PMC8575832 DOI: 10.21037/jtd-21-298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Accepted: 09/16/2021] [Indexed: 11/16/2022]
Abstract
Background Left ventricular assist device (LVAD) has been increasingly used in patients with advanced heart failure. This study aimed to assess the impact of implementation of LVAD therapy on heart transplantation (HTx) service in Hong Kong (HK). Methods LVAD program was started in 2010 in HK and patients who had been put on HTx waiting list since the start of HTx program in HK from 1992 to 2020 were included for analysis. Survival on HTx waiting list between pre-LVAD era 1992–2009 and post-LVAD era 2010–2020 were analyzed by Kaplan-Meier method and compared by log-rank test. Multivariate analysis by time-dependent Cox-proportional hazard model was used to identify independent predictors of HTx waiting list mortality. Results A total of 478 heart transplant listing episodes involving 457 patients were included for analysis. There were 232 heart transplantations (HTxs), including one re-transplantation, during the study period. There were 110 patients who received LVAD as bridge to transplantation (BTT) and 30 of them had undergone subsequent HTx. The 1-, 2- and 3-year survival on waiting list were 82.3%, 61.7% and 43.0% respectively in the pre-LVAD era (n=178), while the 1-, 2- and 3-year survival were significantly improved at 85.7%, 81.8% and 78% respectively in the post-LVAD era (n=300), (P=0.003). Time-dependent multivariate analysis revealed that LVAD support was independently associated with significant reduction of waiting list mortality [odds ratio (OR): 0.21; 95% confidence interval (CI): 0.10–0.44, P<0.001]. There was no significant difference when comparing survival after LVAD as BTT and survival after HTx up to 8 years (76.1% vs. 72% at 8 years respectively, P=0.732). Conclusions Waiting list survival improved in the post-LVAD era driven by the implementation of LVAD service. Long-term survival for LVAD recipients as BTT were comparable to heart transplant recipients in HK.
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Affiliation(s)
- Ka-Lam Wong
- Cardiac Medical Unit, Grantham Hospital, Hong Kong, China
| | - Ka Lai Cally Ho
- Department of Cardiothoracic Surgery, Queen Mary Hospital, Hong Kong, China
| | - Oswald Joseph Lee
- Department of Cardiothoracic Surgery, Queen Mary Hospital, Hong Kong, China
| | - Kin Shing Lun
- Department of Paediatric Cardiology, Queen Mary Hospital, Hong Kong, China
| | - Inderjeet Bhatia
- Department of Cardiothoracic Surgery, Queen Mary Hospital, Hong Kong, China
| | | | | | - Wing Kuk Timmy Au
- Department of Cardiothoracic Surgery, Queen Mary Hospital, Hong Kong, China
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26
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He H, Baka T, Balschi J, Motani AS, Nguyen KK, Liu Q, Slater R, Rock B, Wang C, Hale C, Karamanlidis G, Hartman JJ, Malik FI, Reagan JD, Luptak I. A Novel Small Molecule Troponin Activator Increases Cardiac Contractile Function Without Negative Impact on Energetics. Circ Heart Fail 2021; 15:e009195. [PMID: 34743528 PMCID: PMC8920024 DOI: 10.1161/circheartfailure.121.009195] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Background: Current heart failure (HF) therapies unload the failing heart without targeting the underlying problem of reduced cardiac contractility. Traditional inotropes (i.e. calcitropes) stimulate contractility via energetically costly augmentation of calcium cycling and worsen patient survival. A new class of agents - myotropes - activate the sarcomere directly, independent of calcium. We hypothesize that a novel myotrope TA1 increases contractility without the deleterious myocardial energetic impact of a calcitrope dobutamine. Methods: We determined the effect of TA1 in bovine cardiac myofibrils and human cardiac microtissues, ex vivo in mouse cardiac fibers and in vivo in anesthetized normal rats. Effects of increasing concentrations of TA1 or dobutamine on contractile function, phosphocreatine (PCr) and ATP concentrations and ATP production were assessed by 31P NMR spectroscopy on isolated perfused rat hearts. Results: TA1 increased the rate of myosin ATPase activity in isolated bovine myofibrils and calcium sensitivity in intact mouse papillary fibers. Contractility increased dose dependently in human cardiac microtissues and in vivo in rats as assessed by echocardiography. In isolated rat hearts, TA1 and dobutamine similarly increased rate pressure product (RPP). Dobutamine increased both developed pressure (DevP) and heart rate (HR) accompanied by decreased PCr to ATP ratio and decreased free energy of ATP hydrolysis (ΔG~ATP) and elevated left ventricular end-diastolic pressure (LVEDP). In contrast, the TA1 increased DevP without any effect on HR, LVEDP, PCr/ATP ratio or ΔG~ATP. Conclusions: Novel myotrope, TA1, increased myocardial contractility by sensitizing the sarcomere to calcium without impairing diastolic function or depleting the cardiac energy reserve. Since energetic depletion negatively correlates with long term survival, myotropes may represent a superior alternative to traditional inotropes in heart failure management.
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Affiliation(s)
- Huamei He
- Physiological NMR Core Laboratory, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Tomas Baka
- Institute of Pathophysiology, Faculty of Medicine, Comenius University, Bratislava, Slovakia; Myocardial Biology Unit, Boston University School of Medicine, Boston, MA
| | - James Balschi
- Physiological NMR Core Laboratory, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Alykhan S Motani
- Amgen Research, Department of Cardiometabolic Disorders, Amgen Inc., Thousand Oaks, CA
| | - Kathy K Nguyen
- Amgen Research, Department of Cardiometabolic Disorders, Amgen Inc., Thousand Oaks, CA
| | - Qingxiang Liu
- Amgen Research, Department of Cardiometabolic Disorders, Amgen Inc., Thousand Oaks, CA
| | - Rebecca Slater
- Amgen Research, Department of Cardiometabolic Disorders, Amgen Inc., Thousand Oaks, CA
| | - Brooke Rock
- Amgen Research, Department of Cardiometabolic Disorders, Amgen Inc., Thousand Oaks, CA
| | - Chen Wang
- Amgen Research, Department of Cardiometabolic Disorders, Amgen Inc., Thousand Oaks, CA
| | - Christopher Hale
- Amgen Research, Department of Cardiometabolic Disorders, Amgen Inc., Thousand Oaks, CA
| | - Georgios Karamanlidis
- Amgen Research, Department of Cardiometabolic Disorders, Amgen Inc., Thousand Oaks, CA
| | | | | | - Jeff D Reagan
- Amgen Research, Department of Cardiometabolic Disorders, Amgen Inc., Thousand Oaks, CA
| | - Ivan Luptak
- Myocardial Biology Unit, Boston University School of Medicine, Boston, MA
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Baldetti L, Pagnesi M, Gramegna M, Belletti A, Beneduce A, Pazzanese V, Calvo F, Sacchi S, Van Mieghem NM, den Uil CA, Metra M, Cappelletti AM. Intra-Aortic Balloon Pumping in Acute Decompensated Heart Failure With Hypoperfusion: From Pathophysiology to Clinical Practice. Circ Heart Fail 2021; 14:e008527. [PMID: 34706550 DOI: 10.1161/circheartfailure.121.008527] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Trials on intra-aortic balloon pump (IABP) use in cardiogenic shock related to acute myocardial infarction have shown disappointing results. The role of IABP in cardiogenic shock treatment remains unclear, and new (potentially more potent) mechanical circulatory supports with arguably larger device profile are emerging. A reappraisal of the physiological premises of intra-aortic counterpulsation may underpin the rationale to maintain IABP as a valuable therapeutic option for patients with acute decompensated heart failure and tissue hypoperfusion. Several pathophysiological features differ between myocardial infarction- and acute decompensated heart failure-related hypoperfusion, encompassing cardiogenic shock severity, filling status, systemic vascular resistances rise, and adaptation to chronic (if preexisting) left ventricular dysfunction. IABP combines a more substantial effect on left ventricular afterload with a modest increase in cardiac output and would therefore be most suitable in clinical scenarios characterized by a disproportionate increase in afterload without profound hemodynamic compromise. The acute decompensated heart failure syndrome is characterized by exquisite afterload-sensitivity of cardiac output and may be an ideal setting for counterpulsation. Several hemodynamic variables have been shown to predict response to IABP within this scenario, potentially guiding appropriate patient selection. Finally, acute decompensated heart failure with hypoperfusion may frequently represent an end stage in the heart failure history: IABP may provide sufficient hemodynamic support and prompt end-organ function recovery in view of more definitive heart replacement therapies while preserving ambulation when used with a transaxillary approach.
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Affiliation(s)
- Luca Baldetti
- IRCCS San Raffaele Scientific Institute, Milan, Italy (L.B., M.G., V.P., F.C., S.S., A.M.C.)
| | - Matteo Pagnesi
- Department of Cardiology, ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Italy (M.P., M.M.)
| | - Mario Gramegna
- IRCCS San Raffaele Scientific Institute, Milan, Italy (L.B., M.G., V.P., F.C., S.S., A.M.C.)
| | - Alessandro Belletti
- Cardiac Intensive Care Unit, Department of Anesthesia and Intensive Care (A. Belletti)
| | | | - Vittorio Pazzanese
- IRCCS San Raffaele Scientific Institute, Milan, Italy (L.B., M.G., V.P., F.C., S.S., A.M.C.)
| | - Francesco Calvo
- IRCCS San Raffaele Scientific Institute, Milan, Italy (L.B., M.G., V.P., F.C., S.S., A.M.C.)
| | - Stefania Sacchi
- IRCCS San Raffaele Scientific Institute, Milan, Italy (L.B., M.G., V.P., F.C., S.S., A.M.C.)
| | - Nicolas M Van Mieghem
- Department of Cardiology and Intensive Care Medicine, Thoraxcenter, Erasmus MC, University Medical Center, Rotterdam, the Netherlands (N.M.V.M., C.A.d.U.)
| | - Corstiaan A den Uil
- Department of Cardiology and Intensive Care Medicine, Thoraxcenter, Erasmus MC, University Medical Center, Rotterdam, the Netherlands (N.M.V.M., C.A.d.U.).,Department of Intensive Care Medicine, Maasstad Hospital, Rotterdam, the Netherlands (C.A.d.U.)
| | - Marco Metra
- Department of Cardiology, ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Italy (M.P., M.M.)
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Morris AA, Khazanie P, Drazner MH, Albert NM, Breathett K, Cooper LB, Eisen HJ, O'Gara P, Russell SD. Guidance for Timely and Appropriate Referral of Patients With Advanced Heart Failure: A Scientific Statement From the American Heart Association. Circulation 2021; 144:e238-e250. [PMID: 34503343 DOI: 10.1161/cir.0000000000001016] [Citation(s) in RCA: 94] [Impact Index Per Article: 31.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Among the estimated 6.2 million Americans living with heart failure (HF), ≈5%/y may progress to advanced, or stage D, disease. Advanced HF has a high morbidity and mortality, such that early recognition of this condition is important to optimize care. Delayed referral or lack of referral in patients who are likely to derive benefit from an advanced HF evaluation can have important adverse consequences for patients and their families. A 2-step process can be used by practitioners when considering referral of a patient with advanced HF for consideration of advanced therapies, focused on recognizing the clinical clues associated with stage D HF and assessing potential benefits of referral to an advanced HF center. Although patients are often referred to an advanced HF center to undergo evaluation for advanced therapies such as heart transplantation or implantation of a left ventricular assist device, there are other reasons to refer, including access to the infrastructure and multidisciplinary team of the advanced HF center that offers a broad range of expertise. The intent of this statement is to provide a framework for practitioners and health systems to help identify and refer patients with HF who are most likely to derive benefit from referral to an advanced HF center.
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Schlögl M, Pak ES, Bansal AD, Schell JO, Ganai S, Kamal AH, Swetz KM, Maguire JM, Perrakis A, Warraich HJ, Jones CA. Top Ten Tips Palliative Care Clinicians Should Know About Prognostication in Critical Illness and Heart, Kidney, and Liver Diseases. J Palliat Med 2021; 24:1561-1567. [PMID: 34283924 DOI: 10.1089/jpm.2021.0330] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Specialty palliative care (PC) clinicians are frequently asked to discuss prognosis with patients and their families. When conveying information about prognosis, PC clinicians need also to discuss the likelihood of prolonged hospitalization, cognitive and functional disabilities, and death. As PC moves further and further upstream, it is crucial that PC providers have a broad understanding of curative and palliative treatments for serious diseases and can collaborate in prognostication with specialists. In this article, we present 10 tips for PC clinicians to consider when caring and discussing prognosis for the seriously ill patients along with their caregivers and care teams. This is the second in a three-part series around prognostication in adult and pediatric PC.
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Affiliation(s)
- Mathias Schlögl
- Centre on Aging and Mobility, University Hospital Zurich and City Hospital Waid Zurich, Zurich, Switzerland.,University Clinic for Acute Geriatric Care, City Hospital Waid Zurich, Zurich, Switzerland
| | - Esther S Pak
- Advanced Heart Failure/Transplantation, Philadelphia VA Medical Center, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Amar D Bansal
- Section of Palliative Care and Medical Ethics, Department of General Medicine, Pittsburgh, Pennsylvania, USA.,Division of Renal-Electrolyte, University of Pittsburgh School of Medicine, UPMC Health System, Pittsburgh, Pennsylvania, USA
| | - Jane O Schell
- Section of Palliative Care and Medical Ethics, Department of General Medicine, Pittsburgh, Pennsylvania, USA.,Division of Renal-Electrolyte, University of Pittsburgh School of Medicine, UPMC Health System, Pittsburgh, Pennsylvania, USA
| | - Sabha Ganai
- Department of Surgery, University of North Dakota School of Medicine and Health Sciences, Fargo, North Dakota, USA
| | - Arif H Kamal
- Duke Cancer Institute, Duke University, Durham, North Carolina, USA.,Duke Fuqua School of Business, Duke University, Durham, North Carolina, USA
| | - Keith M Swetz
- Center for Palliative and Supportive Care, Division of Gerontology, Geriatrics, and Palliative Care, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA.,Department of Medicine, Division of Gerontology, Geriatrics and Palliative Care, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Jennifer M Maguire
- Division of Pulmonary and Critical Care Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Aristotelis Perrakis
- Department of General, Visceral, Vascular and Transplant Surgery, University Hospital Magdeburg, Magdeburg, Germany
| | - Haider J Warraich
- Department of Medicine, Brigham and Women's Hospital and Veterans Affairs Boston Healthcare System, Harvard Medical School, Boston, Massachusetts, USA
| | - Christopher A Jones
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
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30
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Polaska P, Jerzak-Wodzynska G, Smigielski W, Gajda J, Rozentryt P, Korewicki J, Sobieszczanska-Malek M, Zielinski T, Rywik TM. Long term outcome of heart failure patients disqualified from heart transplantation. Acta Cardiol 2021; 76:525-533. [PMID: 33432873 DOI: 10.1080/00015385.2020.1852755] [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: 10/22/2022]
Abstract
BACKGROUND The prognosis of patients with advanced heart failure is unfavourable. However, little is known about the survival of patients referred for heart transplantation but finally disqualified from transplantation due to contraindications. This study aimed to evaluate the prognosis of patients' disqualified from heart transplantation. METHODS It was a retrospective study based on medical records of patients disqualified from heart transplantation. RESULTS One hundred and fifty-one patients were included and 94 deaths were recorded during long-term follow-up (range 0.02-10.1 years). The survival rate at 5 years was 25%. The mean age of the studied population was 57.7 years and the majority of patients were males, 87.4%. The ischaemic aetiology (66.2%) was the most dominant aetiology of heart failure. In the Cox regression model, supervision by the specialist cardiology centre (HR 0.61;p = 0.04) and pharmacotherapy with beta-blockers (HR = 0.47;p = 0.02) positively influenced the prognosis. On the contrary, well-known heart failure risk factors like a renal failure (HR 1.59;p = 0.049), pulmonary hypertension (HR 1.55;p = 0.046), liver failure (HR 2.65;p = 0.02) were negative predictors of outcome. By Kaplan-Meier analysis, patients with other than pulmonary hypertension causes of disqualification from heart transplantation had a better survival rate, p = 0.047. CONCLUSIONS The prognosis of patients disqualified from heart transplantation is unfavourable. However, some of the patients experience relatively long survival. Therefore, careful clinical assessment and identification of factors influencing prognosis may improve adequate patients' qualifications for heart transplantation.
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Affiliation(s)
- Paula Polaska
- Heart Failure and Transplantology Department, Cardinal Stefan Wyszynski National Institute of Cardiology, Warsaw, Poland
| | - Grazyna Jerzak-Wodzynska
- Heart Failure and Transplantology Department, Cardinal Stefan Wyszynski National Institute of Cardiology, Warsaw, Poland
| | - Witold Smigielski
- Department of Epidemiology, Cardiovascular Disease Prevention and Health Promotion Cardinal Stefan Wyszynski National Institute of Cardiology, Warsaw, Poland
| | - Janusz Gajda
- Department of Statistics and Econometrics, Faculty of Economic Science, University of Warsaw, Poland
| | - Piotr Rozentryt
- 3rd Department of Cardiology, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Silesia, Katowice, Poland
- Silesian Centre for Heart Disease, Zabrze, Poland
| | - Jerzy Korewicki
- Heart Failure and Transplantology Department, Cardinal Stefan Wyszynski National Institute of Cardiology, Warsaw, Poland
| | | | - Tomasz Zielinski
- Heart Failure and Transplantology Department, Cardinal Stefan Wyszynski National Institute of Cardiology, Warsaw, Poland
| | - Tomasz M. Rywik
- Heart Failure and Transplantology Department, Cardinal Stefan Wyszynski National Institute of Cardiology, Warsaw, Poland
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Chronic Intravenous Inotropic Support as Palliative Therapy and Bridge Therapy for Patients With Advanced Heart Failure: A Single-Center Experience. J Card Fail 2021; 27:974-980. [PMID: 34153459 DOI: 10.1016/j.cardfail.2021.06.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 06/01/2021] [Accepted: 06/02/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Many patients with American College of Cardiology/American Heart Association Stage D (advanced) heart failure are discharged home on chronic intravenous inotropic support (CIIS) as bridge to surgical therapy or as palliative therapy. This study analyzed the clinical trajectory of patients with advanced heart failure who were on home CIIS. METHODS We conducted a single-institution, retrospective cohort study of patients on CIIS between 2010 and 2016 (n = 373), stratified by indication for initiation of inotropic support. Study outcomes were time from initiation of CIIS to cessation of therapy, time to death for patients who did not receive surgical therapy and rates of involvement with palliative care. RESULTS Overall, patients received CIIS therapy for an average of 5.9 months (standard deviation [SD] 7.3). Patients on CIIS as palliative therapy died in an average of 6.2 months (SD 6.6) from the time of initiation of CIIS, and those on CIIS as bridge therapy who did not ultimately receive surgical therapy died after an average of 8.6 months (SD 9.3). Patients who received CIIS as bridge therapy were significantly less likely to receive palliative-care consultation than those on inotropes as palliative therapy, whether or not they underwent surgery. CONCLUSIONS In this large cohort of patients with advanced HF, patients who on CIIS as palliative therapy survived for 6.2 months, on average, with wide variation among patients. Patients who were on CIIS as bridge therapy but did not ultimately receive surgical therapy received less palliative care despite the high mortality rate in this subgroup.
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Herr JJ, Ravichandran A, Sheikh FH, Lala A, Chien CV, Hsiao S, Srivastava A, Pedrotty D, Nowaczyk J, Tompkins S, Ahmed S, Xiang F, Forest S, Tong MZ, D'souza B. Practices of Referring Patients to Advanced Heart Failure Centers. J Card Fail 2021; 27:1251-1259. [PMID: 34146684 DOI: 10.1016/j.cardfail.2021.05.024] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 05/19/2021] [Accepted: 05/19/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND Therapies for advanced heart failure (AHF) improve the likelihood of survival in a growing population of patients with stage D heart failure (HF). Successful implementation of these therapies is dependent upon timely and appropriate referrals to AHF centers. METHODS We performed a retrospective analysis of patients referred to 9 AHF centers for evaluation for AHF therapies. Patients' demographics, referring providers' characteristics, referral circumstances, and evaluation outcomes were collected. RESULTS The majority of referrals (n = 515) were male (73.4%), and a majority of those were in the advanced state of the disease: very low left ventricular ejection fraction (<20% in 51.5%); 59.4% inpatient; and high risk Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) profiles (74.5% profile 1-3). HF cardiologists (49.1%) were the most common originating referral source; the least common (4.9%) were electrophysiologists. Common clinical triggers for referral included worsening HF (30.0%), inotrope dependence (19.6%), hospitalization (19.4%), and cardiogenic shock (17.8%). Most commonly, AHF therapies were not offered because patients were too sick (38.0%-45.1%) or for psychosocial reasons (20.3%-28.6%). Compared to non-HF cardiologists, patients referred by HF cardiologists were offered an AHF therapy more often (66.8% vs 58.4%, P = 0.0489). Of those not offered any AHF therapy, 28.4% received home inotropic therapy, and 14.5% were referred to hospice. CONCLUSIONS In this multicenter review of AHF referrals, HF cardiologists referred the most patients despite being a relatively small proportion of the overall clinician population. Late referral was prevalent in this high-risk patient population and correlates with worsened outcomes, suggesting a significant need for broad clinician education regarding the benefits, triggers and appropriate timing of referral to AHF centers for optimal patient outcomes.
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Affiliation(s)
- Jared J Herr
- Sutter Health CPMC Center for Advanced Heart Failure Therapies, California Pacific Medical Center, San Francisco, California.
| | | | - Farooq H Sheikh
- MedStar Heart and Vascular Institute, Georgetown University, Washington, DC
| | - Anuradha Lala
- Department of Population Health Science and Policy, Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Christopher V Chien
- Division of Cardiology, University of North Carolina, Durham, North Carolina
| | - Stephanie Hsiao
- Sutter Health CPMC Center for Advanced Heart Failure Therapies, California Pacific Medical Center, San Francisco, California
| | - Ajay Srivastava
- Section of Advanced Heart Failure, Department of Cardiology, Scripps Clinic, San Diego, California
| | - Dawn Pedrotty
- Department of Cardiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Jennifer Nowaczyk
- Section of Advanced Heart Failure, Department of Cardiology, Scripps Clinic, San Diego, California
| | | | - Sara Ahmed
- MedStar Heart and Vascular Institute, Georgetown University, Washington, DC
| | - Fei Xiang
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio; Department of Thoracic and Cardiovascular Surgery, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Stephen Forest
- Department of Cardiothoracic Surgery, Montefiore Medical Center, New York, New York
| | - Michael Z Tong
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Benjamin D'souza
- Department of Cardiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
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Outcome Predictors and Safety of Home Dobutamine Intravenous Infusion in End Stage Heart Failure Patients. J Clin Med 2021; 10:jcm10122571. [PMID: 34200733 PMCID: PMC8229659 DOI: 10.3390/jcm10122571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 05/28/2021] [Accepted: 06/07/2021] [Indexed: 11/23/2022] Open
Abstract
Patients in end-stage heart failure can experiment cardiogenic shock and may not be weanable from dobutamine. The fate of these patients is a challenge for doctors, patients, family, and the institution. Dobutamine use at home can be a solution. The aim of the present study was to assess the outcome, biological predictors, and safety of dobutamine use at home in dobutamine-dependent patients. All consecutive dobutamine-dependent patients discharged with continuous home intravenous dobutamine, from a single tertiary center between February 2014 and November 2019, were retrospectively analyzed. A total of 19 patients (age 65 ± 10 years) were followed for one year. At one-year, the survival rate was 32%, (6/19). Five (26%) patients had an adverse event related to the intravenous catheter. In a multivariate logistic regression analysis, the combination of a glomerular filtration rate >60 mL/min and a brain natriuretic peptide level <1000 ng/L, were highly predictive of one-year survival (HR = 10.87, IC95% (5.78–36.44), p < 0.001). Management of dobutamine-unweanable patients after cardiogenic shock may involve dobutamine at home to permit a home return. This strategy allows a significant survival and few readmissions, and, if eligible, access to surgical strategies, such as heart transplantation. Simple biological markers at discharge can identify severe patients to refer to palliative care and good responders.
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Ambulatory advanced heart failure patients: timing of mechanical circulatory support - delaying the inevitable? Curr Opin Cardiol 2021; 36:186-197. [PMID: 33395078 DOI: 10.1097/hco.0000000000000831] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Current indications for continuous-flow left ventricular assist device (cfLVAD) implantation is for patients in cardiogenic shock or inotrope-dependent advanced heart failure. Risk stratification of noninotrope dependent ambulatory advanced heart failure patients is a subject of registries designed to help shared-decision making by clinicians and patients regarding the optimal timing of mechanical circulatory support (MCS). RECENT FINDINGS The Registry Evaluation of Vital Information for VADs in Ambulatory Life enrolled ambulatory noninotrope dependent advanced systolic heart failure patients who had 25% annualized risk of death, MCS, or heart transplantation (HT). Freedom from composite clinical outcome at 1-year follow-up was 23.5% for the entire cohort. Seattle Heart Failure Model Score and Natriuretic pepides were predictors with modest discriminatory power. Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) profile 4 patients had the highest risk (3.7-fold) of death, MCS or HT compared to INTERMACS profile 7. SUMMARY We propose individualized risk stratification for noninotrope dependent ambulatory advanced heart failure patients and include serial changes in end-organ function, nutritional parameters, frailty assessment, echocardiographic and hemodynamic data. The clinical journey of a patient with advanced heart failure should be tracked and discussed at each clinic visit for shared decision-making regarding timing of cfLVAD.
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Johnson JA, Kim SH, Jiang J, Phillips M, Schumacher WA, Bostwick JS, Gargalovic PS, Onorato JM, Luk CE, Generaux C, He Y, Chen XQ, Xu C, Galella MA, Wang T, Gordon DA, Wexler RR, Finlay HJ. Discovery of a Hydroxypyridinone APJ Receptor Agonist as a Clinical Candidate. J Med Chem 2021; 64:3086-3099. [PMID: 33689340 DOI: 10.1021/acs.jmedchem.0c01878] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Apelin-13 is an endogenous peptidic agonist of the apelin receptor (APJ) receptor with the potential for improving cardiac function in heart failure patients. However, the low plasma stability of apelin-13 necessitates continuous intravenous infusion for therapeutic use. There are several approaches to increase the stability of apelin-13 including attachment of pharmacokinetic enhancing groups, stabilized peptides, and Fc-fusion approaches. We sought a small-molecule APJ receptor agonist approach to target a compound with a pharmacokinetic profile amenable for chronic oral administration. This manuscript describes sequential optimization of the pyrimidinone series, leading to pyridinone 14, with in vitro potency equivalent to the endogenous ligand apelin-13 and with an excellent oral bioavailability and PK profile in multiple preclinical species. Compound 14 exhibited robust pharmacodynamic effects similar to apelin-13 in an acute rat pressure-volume loop model and was advanced as a clinical candidate.
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Affiliation(s)
- James A Johnson
- Bristol Myers Squibb Company, Research and Development, P.O. Box 5400, Princeton, New Jersey 08543-5400, United States
| | - Soong-Hoon Kim
- Bristol Myers Squibb Company, Research and Development, P.O. Box 5400, Princeton, New Jersey 08543-5400, United States
| | - Ji Jiang
- Bristol Myers Squibb Company, Research and Development, P.O. Box 5400, Princeton, New Jersey 08543-5400, United States
| | - Monique Phillips
- Bristol Myers Squibb Company, Research and Development, P.O. Box 5400, Princeton, New Jersey 08543-5400, United States
| | - William A Schumacher
- Bristol Myers Squibb Company, Research and Development, P.O. Box 5400, Princeton, New Jersey 08543-5400, United States
| | - Jeffrey S Bostwick
- Bristol Myers Squibb Company, Research and Development, P.O. Box 5400, Princeton, New Jersey 08543-5400, United States
| | - Peter S Gargalovic
- Bristol Myers Squibb Company, Research and Development, P.O. Box 5400, Princeton, New Jersey 08543-5400, United States
| | - Joelle M Onorato
- Bristol Myers Squibb Company, Research and Development, P.O. Box 5400, Princeton, New Jersey 08543-5400, United States
| | - Chiuwa E Luk
- Bristol Myers Squibb Company, Research and Development, P.O. Box 5400, Princeton, New Jersey 08543-5400, United States
| | - Claudia Generaux
- Bristol Myers Squibb Company, Research and Development, P.O. Box 5400, Princeton, New Jersey 08543-5400, United States
| | - Yan He
- Bristol Myers Squibb Company, Research and Development, P.O. Box 5400, Princeton, New Jersey 08543-5400, United States
| | - Xue-Qing Chen
- Bristol Myers Squibb Company, Research and Development, P.O. Box 5400, Princeton, New Jersey 08543-5400, United States
| | - Carrie Xu
- Bristol Myers Squibb Company, Research and Development, P.O. Box 5400, Princeton, New Jersey 08543-5400, United States
| | - Michael A Galella
- Bristol Myers Squibb Company, Research and Development, P.O. Box 5400, Princeton, New Jersey 08543-5400, United States
| | - Tao Wang
- Bristol Myers Squibb Company, Research and Development, P.O. Box 5400, Princeton, New Jersey 08543-5400, United States
| | - David A Gordon
- Bristol Myers Squibb Company, Research and Development, P.O. Box 5400, Princeton, New Jersey 08543-5400, United States
| | - Ruth R Wexler
- Bristol Myers Squibb Company, Research and Development, P.O. Box 5400, Princeton, New Jersey 08543-5400, United States
| | - Heather J Finlay
- Bristol Myers Squibb Company, Research and Development, P.O. Box 5400, Princeton, New Jersey 08543-5400, United States
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Lemogoum D, Kamdem F, Ba H, Ngatchou W, Hye Ndindjock G, Dzudie A, Monkam Y, Mouliom S, Hermans MP, Bika Lele EC, van de Borne P. Epidemiology of acutely decompensated systolic heart failure over the 2003-2013 decade in Douala General Hospital, Cameroon. ESC Heart Fail 2020; 8:481-488. [PMID: 33225620 PMCID: PMC7835589 DOI: 10.1002/ehf2.13098] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 10/09/2020] [Accepted: 10/21/2020] [Indexed: 11/09/2022] Open
Abstract
AIMS Acutely decompensated heart failure (HF) (ADHF) is a common cause of hospitalization and mortality worldwide. This study explores the epidemiology and prognostic factors of ADHF in Cameroonian patients. METHODS AND RESULTS This was a retrospective study conducted between January 2003 and December 2013 from the medical files of patients followed at the intensive care and cardiovascular units of Douala General Hospital in Cameroon. Clinical, electrocardiographic, echocardiographic, and biological data were collected from 142 patients (58.5% men; mean age 58 ± 14 years) hospitalized for ADHF with reduced ejection fraction (HFrEF), whose left ventricular ejection fraction was <50%, or alternatively whose shortening fraction was <28%, both assessed by echocardiography. The commonest risk factors associated with HFrEF were hypertension (59.2%), diabetes mellitus (16.2%), tobacco use (14.1%), and dyslipidaemia (7.7%), respectively. The major causes of HF in hospitalized patients were hypertensive heart disease (40%, n = 57); hypertrophic cardiomyopathy (33.8%, n = 48); and ischemic heart disease (21.8%, n = 31). The most frequent comorbid conditions were atrial fibrillation (25.4%, n = 36) and chronic kidney disease (18.3%, n = 26). Major biological abnormalities included increased bilirubinemia >12 mg/L (87.5%, n = 124); hyperuricaemia >70 mg/L (84.9%, n = 121); elevated serum creatinine (65.6%, n = 93); anaemia (59.1%, n = 84); hyperglycaemia on admission >1.8 g/L (42.3%, n = 60); and hyponatraemia <135 mEq/L (26.8%, n = 38). At admission, 33.8% (n = 48) of patients had no pharmacological treatment for HF. The most frequently used therapies upon admission included furosemide (50%, n = 71), angiotensin-converting enzyme inhibitors (ACEIs; 40.1%, n = 57); spironolactone (35.2%, n = 50); digoxin (26%, n = 37); beta-blockers (17.7%, n = 25); angiotensin-receptor blockers (ARBs; 7%, n = 10); and nitrates (7.0%). The overall in-hospital mortality rate was 20.4%. Factors associated with poor prognosis were systolic blood pressure <90 mmHg [odds ratio (OR) 3.88; confidence interval (CI) 1.36-11.05, P = 0.011], left ventricular ejection fraction <20% (OR 7.48; CI 2.84-19.71, P < 0.001), decreased renal function (OR 1.03; CI 1.00-1.05, P = 0.026), dobutamine use for cardiogenic shock (OR 2.74;CI 1.00-7.47, P = 0.049), pleural fluid effusion (OR 3.46; CI 1.07-11.20, P = 0.038), and prothrombin time <50% (OR 3.60; CI 1.11-11.68, P = 0.033). The use of ACEIs/ARBs was associated with reduced in-hospital mortality rate (OR 0.17; CI 0.02-0.81, P = 0.006). CONCLUSIONS Hypertensive heart disease, hypertrophic cardiomyopathy, and ischemic heart disease are the commonest causes of HF in this Cameroonian population. ADHF is associated with high in-hospital mortality in Cameroon. Hypotension, severe left ventricular systolic dysfunction, renal function impairment, and dobutamine administration were associated with worst acute HF outcomes. ACEIs/ARBs use was associated with improved survival.
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Affiliation(s)
- Daniel Lemogoum
- Faculty of Medicine and Pharmaceutical Sciences, University of Douala, Douala, Cameroon.,Cameroon Heart Institute, Cameroon Heart Foundation, Douala, Cameroon.,Department of Cardiology, ULB-Erasme Hospital, Free Brussels University, Brussels, Belgium
| | - Félicité Kamdem
- Faculty of Medicine and Pharmaceutical Sciences, University of Douala, Douala, Cameroon
| | - Hamadou Ba
- Faculty of Medicine and Biomedical Sciences, University of Yaounde, Yaounde, Cameroon
| | - William Ngatchou
- Faculty of Medicine and Pharmaceutical Sciences, University of Douala, Douala, Cameroon.,Cameroon Heart Institute, Cameroon Heart Foundation, Douala, Cameroon
| | | | - Anasthase Dzudie
- Faculty of Medicine and Biomedical Sciences, University of Yaounde, Yaounde, Cameroon
| | | | - Sidick Mouliom
- Faculty of Medicine and Pharmaceutical Sciences, University of Douala, Douala, Cameroon
| | - Michel P Hermans
- Endocrinology and Nutrition Unit, Cliniques Universitaires St-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Elysée Claude Bika Lele
- Cameroon Heart Institute, Cameroon Heart Foundation, Douala, Cameroon.,Unité de Physiologie et de Médecine des APS, Faculté des Sciences, University of Douala, BP: 7064, Douala, Cameroon
| | - Philippe van de Borne
- Department of Cardiology, ULB-Erasme Hospital, Free Brussels University, Brussels, Belgium
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Reduction of Postoperative Infections Through Routine Preoperative Universal Decolonization of Advanced Heart Failure Patients With Chlorhexidine and Mupirocin Before Left Ventricular Assist Device Implantation: A Single-Center Observational Study. Dimens Crit Care Nurs 2020; 39:312-320. [PMID: 33009271 DOI: 10.1097/dcc.0000000000000443] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Left ventricular assist devices (LVADs) are increasingly being used in patients with advanced heart failure as bridge to transplant, bridge to decision, or destination therapy. Infections are a major complication associated with LVADs. Staphylococcus aureus is one of the common causative organisms associated with LVAD infections. Methicillin resistant staphylococcus aureus (MRSA)-colonized patients are at an increased risk for developing MRSA-associated infections. Various studies have demonstrated decolonization of skin with topical chlorhexidine and nares with 2% intranasal mupirocin ointment is effective in reducing MRSA-associated infections. OBJECTIVE The objective of this observational study was to examine the impact of a universal decolonization protocol using topical chlorhexidine and intranasal mupirocin ointment for 5 days before LVAD implantation on postoperative infections (30, 60, and 90 days) and 30-day infection-related rehospitalization. METHODS A preoperative universal decolonization with 4% chlorhexidine daily whole-body bath and 2% intranasal mupirocin ointment twice a day for 5 days was implemented for patients undergoing elective LVAD implantation. Using an observational study design, we included a convenience sample of 84 subjects who were established patients in an accredited advanced heart failure program. Thirty-seven patients served in the standard protocol group, and 47 in the universal decolonization protocol group participated in the observational study. RESULTS In the standard protocol group, there were 4 MRSA infections with none in the universal decolonization group (χ = 5.34, P = .03). In total, there were 8 surgical site infections in the standard protocol group and 1 in the universal decolonization group (χ = 5.95, P = .01). CONCLUSION A 5-day universal decolonization protocol before LVAD implantation was effective in reducing total infections as well as MRSA-specific infections.
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Snipelisky D, Fudim M, Perez A, Nayor M, Lever NM, Raymer DS, Rosenbaum AN, AbouEzzeddine O, Hernandez AF, Stevenson LW, Gilstrap LG. Expected vs Actual Outcomes of Elective Initiation of Inotropic Therapy During Heart Failure Hospitalization. MAYO CLINIC PROCEEDINGS: INNOVATIONS, QUALITY & OUTCOMES 2020; 4:529-536. [PMID: 33083701 PMCID: PMC7557209 DOI: 10.1016/j.mayocpiqo.2020.05.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Objective To describe the intent and early outcomes of elective inotrope use during heart failure hospitalization. Patients and Methods A prospective multisite design was used to collect data for hemodynamically stable patients started electively on inotrope therapy between January 1 and August 31, 2018. We prospectively recorded data when intravenous inotropic therapy was initiated, including survey of the attending cardiologists regarding expectations for the clinical course. Patients were followed up for events through hospital discharge and an additional survey was administered at the end of hospitalization. Results For the 92 patients enrolled, average age was 60 years and ejection fraction was 24%±12%. At the time of inotrope initiation, attending heart failure cardiologists predicted that 50% (n=46) of the patients had a “high or very high” likelihood of becoming dependent on intravenous inotropic therapy and 58% (n=53) had a “high” likelihood of death, transplant, or durable ventricular assist device placement within the next 6 months. Provider predictions regarding death/hospice or need for continued home infusions were accurate only 51% (47 of 92) of the time. Only half the patients (n=47) had goals-of-care conversations before inotrope treatment initiation. Conclusion More than half the patients (51 of 92) electively started on inotrope treatment without present or imminent cardiogenic shock ultimately required home inotrope therapy, died during admission, or were discharged with hospice. Heart failure clinicians could not reliably identify those patients at the time of inotrope therapy initiation and goals-of-care discussions were not frequently performed.
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Lee EC, McNitt S, Martens J, Bruckel JT, Chen L, Alexis JD, Storozynsky E, Thomas S, Gosev I, Barrus B, Goldenberg I, Vidula H. Long-term milrinone therapy as a bridge to heart transplantation: Safety, efficacy, and predictors of failure. Int J Cardiol 2020; 313:83-88. [PMID: 32320777 DOI: 10.1016/j.ijcard.2020.04.055] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Revised: 02/09/2020] [Accepted: 04/17/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Studies of long-term inotrope use in advanced HF have previously provided limited and conflicting results. This study aimed to evaluate the safety and efficacy of long-term milrinone use and identify predictors of failure to bridge to orthotropic heart transplant (OHT) in a cohort of end-stage heart failure (HF) patients listed for heart transplantation and receiving inotrope therapy. METHODS The study included 150 adults listed for OHT at a single center from 2001 to 2017 who received milrinone therapy for ≥30 days. Multivariate Cox proportional hazards models were used to identify factors associated with "failure" (left ventricular assist device, intra-aortic balloon pump, status downgrade due to instability, death) vs. "success" (OHT, recovery) during bridging to OHT. RESULTS "Failure" occurred in 33 (22%) patients. Factors independently associated with failure included male sex (HR = 7.6; p = 0.004), no implantable cardioverter-defibrillator (HR = 3.8; p = 0.009), and lack of guideline-directed medical therapy (GDMT) with a beta-blocker (HR = 7.8; p = 0.002) or angiotensin-converting enzyme inhibitor/angiotensin receptor blocker (HR = 6.3; p < 0.001). Patients who received fewer guideline-directed medications had a higher cumulative probability of failure. Adverse events included central line-associated bloodstream infection (2.55 per 1000 line-days) and arrhythmia (1.59 per 1000 treatment-days). CONCLUSIONS Our findings suggest that long-term milrinone therapy in selected patients is associated with a high rate of successful bridging to OHT and a low rate of adverse events. Patients intolerant of GDMT are more likely to fail to bridge to OHT without mechanical support. Sex differences in outcomes associated with milrinone therapy should be explored.
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Affiliation(s)
- Elizabeth C Lee
- Division of Cardiology, Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA.
| | - Scott McNitt
- Division of Cardiology, Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - John Martens
- Division of Cardiology, Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Jeffrey T Bruckel
- Division of Cardiology, Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Leway Chen
- Division of Cardiology, Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Jeffrey D Alexis
- Division of Cardiology, Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Eugene Storozynsky
- Division of Cardiology, Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Sabu Thomas
- Division of Cardiology, Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Igor Gosev
- Division of Cardiac Surgery, Department of Surgery, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Bryan Barrus
- Division of Cardiac Surgery, Department of Surgery, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Ilan Goldenberg
- Division of Cardiology, Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Himabindu Vidula
- Division of Cardiology, Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
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Cost-Effectiveness of Long-Term Left Ventricular Assist Device Support: Is the Extra-Welfarist Model Suitable for Advanced Heart Failure? ASAIO J 2020; 66:871-874. [PMID: 32740344 DOI: 10.1097/mat.0000000000001243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Network Meta-Analysis of the Safety of Drug Therapy for Cardiogenic Shock. JOURNAL OF HEALTHCARE ENGINEERING 2020; 2020:8862256. [PMID: 32802302 PMCID: PMC7416258 DOI: 10.1155/2020/8862256] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Revised: 06/02/2020] [Accepted: 07/01/2020] [Indexed: 11/17/2022]
Abstract
Objectives (1) To conduct a network meta-analysis of clinical drugs used for cardiogenic shock and (2) provide evidence for the selection of medication for the treatment of this condition. Methods PubMed, EMBASE, Cochrane library, China HowNet (CNKI), Wanfang database, and Weipu database were searched using keywords Dopamine, Dobutamine, Epinephrine, Adrenaline, Norepinephrine, Noradrenaline, Milrinone, Natriuretic peptide, Recombinant human brain natriuretic peptide, Levosimendan, Cardiac shock, and Cardiogenic shock. We select literature according to prespecified inclusion and exclusion criteria and record data such as drug type, mortality, and adverse reactions. Results Twenty-eight of 1387 articles met inclusion criteria, comprising 1806 patients who suffered from cardiogenic shock. Dopamine, dobutamine, epinephrine, norepinephrine, milrinone, recombinant human brain natriuretic peptide, and levosimendan were all commonly used in the treatment of cardiogenic shock. Milrinone was most effective at reducing mortality and had the lowest incidence of adverse reactions. Conclusion This network meta-analysis demonstrated that milrinone was the most effective medication at reducing mortality and adverse events in patients suffering from cardiogenic shock.
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Safety of Outpatient Milrinone Infusion in End-Stage Heart Failure: ICD-Level Data on Atrial Fibrillation and Ventricular Tachyarrhythmias. Am J Med 2020; 133:857-864. [PMID: 31883773 DOI: 10.1016/j.amjmed.2019.11.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 11/22/2019] [Accepted: 11/25/2019] [Indexed: 11/20/2022]
Abstract
BACKGROUND Milrinone infusion is one of a few select "non-device" therapies for patients with New York Heart Association (NYHA) class IV, stage D heart failure, which has been associated with an increase in ventricular tachyarrhythmia and atrial fibrillation. Milrinone improves hemodynamics and provides symptomatic relief. Many patients with end-stage heart failure die from cardiac pump failure, and the impact of ventricular tachyarrhythmia and atrial fibrillation on their mortality is unclear. METHODS This is a retrospective study of 98 consecutive patients receiving outpatient milrinone in a single center from 2008 to 2016. The primary endpoint of the study was overall survival on milrinone. Secondary endpoints were incidence of post-milrinone implantable cardioverter defibrillator (ICD) shocks and development of ventricular tachyarrhythmia or atrial fibrillation. RESULTS Median survival was 581 ± 96 days with no difference between those with prior ventricular tachyarrhythmia and those without at 1 month (92% vs 97%, P = 0.34), 6 months (67% vs 73%, P = 0.75), and 12 months (67% vs 61%, P = 0.88). Seven out of 12 (58%) patients with prior ventricular tachyarrhythmia had ICD shocks, as compared to 5 out of 78 (6.4%) (P <0.001). Thirty-five patients had atrial fibrillation prior to starting milrinone, which decreased to 72% (P <0.05) by the third follow-up time period (7-9 months). Amiodarone use was protective against new onset atrial fibrillation. CONCLUSIONS Patients with stage D heart failure with a history of ventricular tachyarrhythmia have similar survival on outpatient milrinone compared to those without. However, those with prior ventricular tachyarrhythmia received more ICD shocks for more ventricular tachyarrhythmias. Milrinone remains a viable therapy for patients with stage D heart failure with limited therapeutic options.
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Latimer A, Pope ND, McFarlin JM. "I Just Feel Like I Always Did": Inotropic Dependency at End of Life. Am J Hosp Palliat Care 2020; 37:497-502. [PMID: 31714150 DOI: 10.1177/1049909119886302] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Patients not considered for mechanical circulatory support or heart transplant may be dependent on inotropic therapy at end of life. End-of-life conversations in advanced heart failure can be challenging for providers, but guidelines recommend frequent goals-of-care conversations when inotropes are used as a palliative treatment. The purpose of this study was to identify aspects of care pertinent for health-care professionals working with patients in end-stage heart failure who are receiving continuous inotropic support. METHODS Qualitative analysis was used to examine 3 audio-recorded semistructured interviews with 1 patient, her family, and her cardiologist. The selected patient was an older adult, diagnosed with advanced heart failure, and dependent on continuous inotropic therapy with no other advanced treatment options available. RESULTS The analysis revealed that (1) reliance on others, (2) contending with uncertainty, and (3) deciding when to discontinue inotropic support were identified as themes central to the patient's and provider's experience. CONCLUSION This study offers insight into how to best support and communicate with patients having advanced heart failure who are dependent on continuous inotropic therapy at end of life.
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Affiliation(s)
- Abigail Latimer
- College of Social Work, University of Kentucky, Lexington, KY, USA
| | - Natalie D Pope
- College of Social Work, University of Kentucky, Lexington, KY, USA
| | - Jessica M McFarlin
- Division of Palliative and Supportive Care, University of Kentucky, Lexington, KY, USA
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Morris AA, Vega JD. True, true, and possibly unrelated: Variability in donor heart acceptance practices across the United States. Am J Transplant 2020; 20:1477-1479. [PMID: 32185879 DOI: 10.1111/ajt.15855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Revised: 02/06/2020] [Accepted: 02/25/2020] [Indexed: 01/25/2023]
Affiliation(s)
- Alanna A Morris
- Department of Medicine, Emory University, Atlanta, Georgia, USA.,Department of Surgery, Emory University, Atlanta, Georgia, USA
| | - J David Vega
- Department of Medicine, Emory University, Atlanta, Georgia, USA.,Department of Surgery, Emory University, Atlanta, Georgia, USA
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Egbuche O, Hanna B, Onuorah I, Uko E, Taha Y, Ghali JK, Onwuanyi A. Contemporary Pharmacologic Management of Heart Failure with Reduced Ejection Fraction: A Review. Curr Cardiol Rev 2020; 16:55-64. [PMID: 31288726 PMCID: PMC7393599 DOI: 10.2174/1573403x15666190709185011] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Revised: 06/11/2019] [Accepted: 06/21/2019] [Indexed: 12/11/2022] Open
Abstract
Heart failure with reduced ejection fraction (HFrEF) is defined as the presence of typical symptoms of heart failure (HF) and a left ventricular ejection fraction ≤ 40%. HFrEF patients constitute approximately 50% of all patients with clinical HF. Despite breakthrough discoveries and advances in the pharmacologic management of HF, HFrEF patients continue to pose a significant economic burden due to a progressive disease characterized by recurrent hospitalizations and need for advanced therapy. Although there are effective, guideline-directed medical therapies for patients with HFrEF, a significant proportion of these patients are either not on appropriate medications’ combination or on optimal tolerable medications’ doses. Since the morbidity and mortality benefits of some of the pharmacologic therapies are dose-dependent, optimal medical therapy is required to impact the burden of disease, quality of life, prognosis, and to curb health care expenditure. In this review, we summarize landmark trials that have impacted the management of HF and we review contemporary pharmacologic management of patients with HFrEF. We also provide insight on general considerations in the management of HFrEF in specific populations. We searched PubMed, Scopus, Medline and Cochrane library for relevant articles published until April 2019 using the following key words “heart failure”, “management”, “treatment”, “device therapy”, “reduced ejection fraction”, “guidelines”, “guideline directed medical therapy”, “trials” either by itself or in combination. We also utilized the cardiology trials portal to identify trials related to heart failure. We reviewed guidelines, full articles, review articles and clinical trials and focused on the pharmacologic management of HFrEF.
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Affiliation(s)
- Obiora Egbuche
- Division of Cardiovascular Disease, Morehouse School of Medicine, Atlanta, GA 30303, United States
| | - Bishoy Hanna
- Division of Cardiovascular Disease, Morehouse School of Medicine, Atlanta, GA 30303, United States
| | - Ifeoma Onuorah
- Division of Cardiovascular Disease, Emory University Hospital, Atlanta, GA 30322, United States
| | - Emmanuela Uko
- Division of Peadiatric Medicine, Icahn School of Medicine at Mount Sinai, NYC, New York, United States
| | - Yasir Taha
- Division of Cardiovascular Disease, Morehouse School of Medicine, Atlanta, GA 30303, United States
| | - Jalal K Ghali
- Division of Cardiovascular Disease, Morehouse School of Medicine, Atlanta, GA 30303, United States
| | - Anekwe Onwuanyi
- Division of Cardiovascular Disease, Morehouse School of Medicine, Atlanta, GA 30303, United States
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McGuinty C, Leong D, Weiss A, MacIver J, Kaya E, Hurlburt L, Billia F, Ross H, Wentlandt K. Heart Failure: A Palliative Medicine Review of Disease, Therapies, and Medications With a Focus on Symptoms, Function, and Quality of Life. J Pain Symptom Manage 2020; 59:1127-1146.e1. [PMID: 31866489 DOI: 10.1016/j.jpainsymman.2019.12.357] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Revised: 12/09/2019] [Accepted: 12/11/2019] [Indexed: 12/11/2022]
Abstract
Despite significant advances in heart failure (HF) treatment, HF remains a progressive, extremely symptomatic, and terminal disease with a median survival of 2.1 years after diagnosis. HF often leads to a constellation of symptoms, including dyspnea, fatigue, depression, anxiety, insomnia, pain, and worsened cognitive function. Palliative care is an approach that improves the quality of life of patients and their caregivers facing the problems associated with life-threatening illness and therefore is well suited to support these patients. However, historically, palliative care has often focused on supporting patients with malignant disease, rather than a progressive chronic disease such as HF. Predicting mortality in patients with HF is challenging. The lack of obvious transition points in disease progression also raises challenges to primary care providers and specialists to know at what point to integrate palliative care during a patient's disease trajectory. Although therapies for HF often result in functional and symptomatic improvements including health-related quality of life (HRQL), some patients with HF do not demonstrate these benefits, including those patients with a preserved ejection fraction. Provision of palliative care for patients with HF requires an understanding of HF pathogenesis and common medications used for these patients, as well as an approach to balancing life-prolonging and HRQL care strategies. This review describes HF and current targeted therapies and their effects on symptoms, hospital admission rates, exercise performance, HRQL, and survival. Pharmacological interactions with and precautions related to commonly used palliative care medications are reviewed. The goal of this review is to equip palliative care clinicians with information to make evidence-based decisions while managing the balance between optimal disease management and patient quality of life.
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Affiliation(s)
- Caroline McGuinty
- Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada; Division of Cardiology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Derek Leong
- Department of Pharmacy, University Health Network, Toronto, Ontario, Canada
| | - Andrea Weiss
- Division of Palliative Care, Department of Supportive Care, University Health Network, Toronto, Ontario, Canada; Division of Palliative Care, Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Jane MacIver
- Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada; Division of Cardiology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Ebru Kaya
- Division of Palliative Care, Department of Supportive Care, University Health Network, Toronto, Ontario, Canada
| | - Lindsay Hurlburt
- Division of Palliative Care, Department of Supportive Care, University Health Network, Toronto, Ontario, Canada; Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada
| | - Filio Billia
- Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada; Division of Cardiology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Heather Ross
- Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada; Division of Cardiology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Kirsten Wentlandt
- Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada; Division of Palliative Care, Department of Supportive Care, University Health Network, Toronto, Ontario, Canada; Division of Palliative Care, Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada.
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Briasoulis A, Adegbala O, Akintoye E, Alvarez P. Temporal trends and outcomes of patients waiting on left ventricular assist devices and inotropes for heart transplantation. Clin Transplant 2020; 34:e13857. [PMID: 32167606 DOI: 10.1111/ctr.13857] [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: 01/20/2020] [Revised: 02/20/2020] [Accepted: 03/10/2020] [Indexed: 11/29/2022]
Abstract
We sought to evaluate the trends and outcomes of patients with left ventricular assist devices (LVADs) and inotropes at the time of listing for heart transplantation. Adults with an LVAD implanted and listed with 1A status were identified in the United Network for Organ Sharing (UNOS) registry between 2010 and 2017. Patients were grouped according to the presence or absence of inotropes at the time of listing and transplantation. A total of 2714 patients were included in the study including 664 patients on inotropes at the time of listing, 235 at the time of transplantation, and 118 on inotropes both at listing and at the time of transplantation. Patients on LVAD and inotropes at the time of listing were more frequently supported with a right ventricular assist device (RVAD) (P < .001), had higher risk of death in the waiting list (sub-hazard ratio [SHR] = 1.48, 95% CI 1.14-1.90, P = .002), and were less likely to be transplanted (SHR = 0.70, 95% CI 0.63-0.78, P < .001) compared with those not on inotropes, after adjusting for described confounders. Approximately 1 in 10 LVAD recipients listed as status 1A are on inotropic therapy at the time of heart transplantation. Patients on LVAD and inotropes have worse outcomes in terms of survival and lower rates of transplantation.
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Affiliation(s)
- Alexandros Briasoulis
- Section of Heart Failure and Transplant, Division of Cardiovascular Diseases, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Oluwole Adegbala
- Division of Cardiology, Wayne State University/Detroit Medical Center, Detroit, Michigan, USA
| | - Emmanuel Akintoye
- Section of Heart Failure and Transplant, Division of Cardiovascular Diseases, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Paulino Alvarez
- Section of Heart Failure and Transplant, Division of Cardiovascular Diseases, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
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Slavin SD, Warraich HJ. El momento óptimo para comenzar los cuidados paliativos en insuficiencia cardiaca: una revisión narrativa. Rev Esp Cardiol 2020. [DOI: 10.1016/j.recesp.2019.07.028] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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