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Chyou JY, Qin H, Butler J, Voors AA, Lam CSP. Sex-related similarities and differences in responses to heart failure therapies. Nat Rev Cardiol 2024; 21:498-516. [PMID: 38459252 DOI: 10.1038/s41569-024-00996-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/01/2024] [Indexed: 03/10/2024]
Abstract
Although sex-related differences in the epidemiology, risk factors, clinical characteristics and outcomes of heart failure are well known, investigations in the past decade have shed light on an often overlooked aspect of heart failure: the influence of sex on treatment response. Sex-related differences in anatomy, physiology, pharmacokinetics, pharmacodynamics and psychosocial factors might influence the response to pharmacological agents, device therapy and cardiac rehabilitation in patients with heart failure. In this Review, we discuss the similarities between men and women in their response to heart failure therapies, as well as the sex-related differences in treatment benefits, dose-response relationships, and tolerability and safety of guideline-directed medical therapy, device therapy and cardiac rehabilitation. We provide insights into the unique challenges faced by men and women with heart failure, highlight potential avenues for tailored therapeutic approaches and call for sex-specific evaluation of treatment efficacy and safety in future research.
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Affiliation(s)
- Janice Y Chyou
- Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Hailun Qin
- Department of Cardiology, University of Groningen, University Medical Centre Groningen, Groningen, Netherlands
| | - Javed Butler
- Department of Medicine, University of Mississippi School of Medicine, Jackson, MS, USA
- Baylor Scott and White Research Institute, Dallas, TX, USA
| | - Adriaan A Voors
- Department of Cardiology, University of Groningen, University Medical Centre Groningen, Groningen, Netherlands
| | - Carolyn S P Lam
- National Heart Centre Singapore and Duke-NUS Medical School, Singapore, Singapore.
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2
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Reed RD, Locke JE. Mitigating Health Disparities in Transplantation Requires Equity, Not Equality. Transplantation 2024; 108:100-114. [PMID: 38098158 PMCID: PMC10796154 DOI: 10.1097/tp.0000000000004630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
Despite decades of research and evidence-based mitigation strategies, disparities in access to transplantation persist for all organ types and in all stages of the transplant process. Although some strategies have shown promise for alleviating disparities, others have fallen short of the equity goal by providing the same tools and resources to all rather than tailoring the tools and resources to one's circumstances. Innovative solutions that engage all stakeholders are needed to achieve equity regardless of race, sex, age, socioeconomic status, or geography. Mitigation of disparities is paramount to ensure fair and equitable access for those with end-stage disease and to preserve the trust of the public, upon whom we rely for their willingness to donate organs. In this overview, we present a summary of recent literature demonstrating persistent disparities by stage in the transplant process, along with policies and interventions that have been implemented to combat these disparities and hypotheses for why some strategies have been more effective than others. We conclude with future directions that have been proposed by experts in the field and how these suggested strategies may help us finally arrive at equity in transplantation.
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Affiliation(s)
- Rhiannon D. Reed
- Comprehensive Transplant Institute, University of Alabama at Birmingham, Birmingham, AL
| | - Jayme E. Locke
- Comprehensive Transplant Institute, University of Alabama at Birmingham, Birmingham, AL
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3
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Kelty CE, Dickinson MG, Lyerla R, Chillag K, Fogarty KJ. Non-Medical Characteristics Affect Referral for Advanced Heart Failure Services: a Retrospective Review. J Racial Ethn Health Disparities 2023:10.1007/s40615-023-01879-w. [PMID: 38038903 PMCID: PMC11143079 DOI: 10.1007/s40615-023-01879-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 11/16/2023] [Accepted: 11/20/2023] [Indexed: 12/02/2023]
Abstract
BACKGROUND Patients with advanced heart failure (AHF) are extensively evaluated before heart transplantation or left ventricular assist device (LVAD) eligibility. Patients are assessed for medical need and psychosocial or economic factors that may affect success post-treatment. For patients to be evaluated, however, they first must be referred. This study investigated social and economic factors affecting AHF referral, specialist visits, or treatment. METHODS Patients with heart failure (n = 24,258) were reviewed at one large hospital system over 4 years. Independent variables age, sex, marital status, race/ethnicity, preferred language, smoking, and insurance status were assessed for the outcomes of referral, clinic visit, and treatment by Chi-square and ANOVA. In-house and 1-year mortality were evaluated by logistic regression, and time-to-event was assessed by the Cox proportional hazards model. RESULTS Younger (HR 0.934, 95% CI 0.925-0.943), male (HR 2.216, 95% CI 1.544-3.181), and publicly insured (HR 1.298 [95% CI 1.038, 1.623]) patients were more likely to be referred, while unmarried (HR 0.665, 95% CI 0.488-0.905) and smoking (HR 0.549, 95% CI 0.389-0.776) patients had fewer referrals. Younger, married, and nonsmoking patients were more likely to have a clinic visit. Younger age, White race, and Hispanic/Latino ethnicity were associated with receiving a heart transplant, and LVAD recipients were more likely Hispanic/Latino ethnicity. Advanced age, Hispanic/Latino ethnicity, and smoking were associated with 1-year mortality after heart failure diagnosis. CONCLUSIONS Disparities in access exist before evaluation for AHF therapies. Improving access at the levels of referral and evaluation is a necessary step toward achieving equity in organ allocation.
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Affiliation(s)
- Catherine E Kelty
- Interdisciplinary Health Sciences PhD Program, Western Michigan University, Kalamazoo, MI, USA.
- Frederik Meijer Heart & Vascular Institute, Corewell Health, Grand Rapids, MI, USA.
- Division of Nephrology, Indiana University School of Medicine, Indianapolis, IN, USA.
| | - Michael G Dickinson
- Frederik Meijer Heart & Vascular Institute, Corewell Health, Grand Rapids, MI, USA
| | - Rob Lyerla
- Interdisciplinary Health Sciences PhD Program, Western Michigan University, Kalamazoo, MI, USA
| | - Kata Chillag
- Department of Public Health, Davidson College, Davidson, NC, USA
| | - Kieran J Fogarty
- Interdisciplinary Health Sciences PhD Program, Western Michigan University, Kalamazoo, MI, USA
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4
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Zhang Y, Aaronson KD, Gryak J, Wittrup E, Minoccheri C, Golbus JR, Najarian K. Predicting need for heart failure advanced therapies using an interpretable tropical geometry-based fuzzy neural network. PLoS One 2023; 18:e0295016. [PMID: 38015947 PMCID: PMC10684094 DOI: 10.1371/journal.pone.0295016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 11/13/2023] [Indexed: 11/30/2023] Open
Abstract
BACKGROUND Timely referral for advanced therapies (i.e., heart transplantation, left ventricular assist device) is critical for ensuring optimal outcomes for heart failure patients. Using electronic health records, our goal was to use data from a single hospitalization to develop an interpretable clinical decision-making system for predicting the need for advanced therapies at the subsequent hospitalization. METHODS Michigan Medicine heart failure patients from 2013-2021 with a left ventricular ejection fraction ≤ 35% and at least two heart failure hospitalizations within one year were used to train an interpretable machine learning model constructed using fuzzy logic and tropical geometry. Clinical knowledge was used to initialize the model. The performance and robustness of the model were evaluated with the mean and standard deviation of the area under the receiver operating curve (AUC), the area under the precision-recall curve (AUPRC), and the F1 score of the ensemble. We inferred membership functions from the model for continuous clinical variables, extracted decision rules, and then evaluated their relative importance. RESULTS The model was trained and validated using data from 557 heart failure hospitalizations from 300 patients, of whom 193 received advanced therapies. The mean (standard deviation) of AUC, AUPRC, and F1 scores of the proposed model initialized with clinical knowledge was 0.747 (0.080), 0.642 (0.080), and 0.569 (0.067), respectively, showing superior predictive performance or increased interpretability over other machine learning methods. The model learned critical risk factors predicting the need for advanced therapies in the subsequent hospitalization. Furthermore, our model displayed transparent rule sets composed of these critical concepts to justify the prediction. CONCLUSION These results demonstrate the ability to successfully predict the need for advanced heart failure therapies by generating transparent and accessible clinical rules although further research is needed to prospectively validate the risk factors identified by the model.
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Affiliation(s)
- Yufeng Zhang
- Department of Computational Medicine and Bioinformatics, University of Michigan, Ann Arbor, Michigan, United States of America
| | - Keith D. Aaronson
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan, United States of America
| | - Jonathan Gryak
- Department of Computer Science, Queens College, City University of New York, New York, New York, United States of America
| | - Emily Wittrup
- Department of Computational Medicine and Bioinformatics, University of Michigan, Ann Arbor, Michigan, United States of America
| | - Cristian Minoccheri
- Department of Computational Medicine and Bioinformatics, University of Michigan, Ann Arbor, Michigan, United States of America
| | - Jessica R. Golbus
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan, United States of America
| | - Kayvan Najarian
- Department of Computational Medicine and Bioinformatics, University of Michigan, Ann Arbor, Michigan, United States of America
- Michigan Institute for Data Science, University of Michigan, Ann Arbor, Michigan, United States of America
- Department of Electrical Engineering and Computer Science, University of Michigan, Ann Arbor, Michigan, United States of America
- Department of Emergency Medicine, University of Michigan, Ann Arbor, Michigan, United States of America
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5
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Masarone D, Kittleson MM, Falco L, Martucci ML, Catapano D, Brescia B, Petraio A, De Feo M, Pacileo G. The ABC of Heart Transplantation-Part 1: Indication, Eligibility, Donor Selection, and Surgical Technique. J Clin Med 2023; 12:5217. [PMID: 37629260 PMCID: PMC10455167 DOI: 10.3390/jcm12165217] [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: 07/21/2023] [Revised: 08/04/2023] [Accepted: 08/09/2023] [Indexed: 08/27/2023] Open
Abstract
Cardiac transplantation represents the gold standard of treatment for selected patients with advanced heart failure who have poor functional capacity and prognosis despite guideline-directed medical therapy and device-based therapy. Proper patient selection and appropriate referral of patients to centers for the treatment of advanced heart failure are the first but decisive steps for screening patients eligible for cardiac transplantation. The eligibility and the decision to list for cardiac transplantation, even for patients with relative contraindications, are based on a multidisciplinary evaluation of a transplant team. This review will discuss the practical indications, the process of patient eligibility for cardiac transplantation, the principle of donor selection, as well as the surgical technique.
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Affiliation(s)
- Daniele Masarone
- Heart Failure Unit, Department of Cardiology, AORN dei Colli-Monaldi Hospital, 80131 Naples, Italy
| | - Michelle M. Kittleson
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Hospital, Los Angeles, CA 90048, USA
| | - Luigi Falco
- Heart Failure Unit, Department of Cardiology, AORN dei Colli-Monaldi Hospital, 80131 Naples, Italy
| | - Maria L. Martucci
- Heart Failure Unit, Department of Cardiology, AORN dei Colli-Monaldi Hospital, 80131 Naples, Italy
| | - Dario Catapano
- Heart Failure Unit, Department of Cardiology, AORN dei Colli-Monaldi Hospital, 80131 Naples, Italy
| | - Benedetta Brescia
- Department of Experimental Medicine, University of Campania “Luigi Vanvitelli”, 80131 Naples, Italy
| | - Andrea Petraio
- Heart Transplant Unit, Department of Cardiac Surgery and Transplants, AORN dei Colli Monaldi Hospital, 80131 Naples, Italy
| | - Marisa De Feo
- Cardiac Surgery Unit, Department of Cardiac Surgery and Transplants, AORN dei Colli Monaldi Hospital, 80131 Naples, Italy
| | - Giuseppe Pacileo
- Heart Failure Unit, Department of Cardiology, AORN dei Colli-Monaldi Hospital, 80131 Naples, Italy
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Impact of Late Referral on Cardiac Transplant Outcomes. Heart Lung Circ 2022; 31:1524-1530. [PMID: 35985947 DOI: 10.1016/j.hlc.2022.06.693] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 05/16/2022] [Accepted: 06/20/2022] [Indexed: 01/26/2023]
Abstract
BACKGROUND Late referral for heart transplantation (HTx) is associated with worse patient outcomes. There are no universally accepted definitions of what constitutes a timely referral for HTx assessment. OBJECTIVES To evaluate the impact of late referral (LR) on HTx outcomes. METHODS This single-centre retrospective observational study included 80 patients undergoing HTx between 2016-2019. We applied a simple clinical tool, derived from markers of advanced heart failure (HF), to classify LR in HTx patients and assess the impact of LR on HTx outcomes. Outcome measures included duration of intensive care unit (ICU) stay, total hospitalisation stay, cost of transplant admission and one-year mortality. RESULTS Based upon the clinical profile, LR was defined by the presence of four or more out of 10 criteria for more than 6 months in HTx patients. In this model, 34 patients were timely referrals and 46 were LR. Patients who were LR had: a longer median time between initial diagnosis and referral (3 vs 7 ys; p=0.03); more features of advanced HF, including inotrope requirements (p=0.004); more comorbidities (p=0.014); and hospitalisations (p<0.0001). Late referral was not associated with longer ICU (p=0.14) or hospital stay (p=0.051), however LR incurred greater total in-hospital costs (p=0.011). There was no difference in one-year mortality (6% vs 9%; p=0.64). CONCLUSION Patients referred late for HTx are more unwell at time of referral and require greater in-hospital resource usage at the time of transplantation. Earlier referral for transplant assessment in patients with advanced HF should be encouraged.
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Kao DP. Electronic Health Records and Heart Failure. Heart Fail Clin 2022; 18:201-211. [PMID: 35341535 PMCID: PMC9167063 DOI: 10.1016/j.hfc.2021.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Increasing the global adoption of electronic health records (EHRs) is transforming the delivery of clinical care. EHRs offer tools that are useful in the care of heart failure ranging from individualized risk stratification and decision support to population management. EHR tools can be combined to target specific areas of need such as the standardization of care, improved quality of care, and resource management. Leveraging EHR functionality has been shown to improve select outcomes including guideline-based therapies, reduction in adverse clinical outcomes, and improved cost-efficiency. Central to success is participation by clinicians and patients in the design and feedback of EHR tools.
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Affiliation(s)
- David P Kao
- University of Colorado School of Medicine, 12700 East 19th Avenue Box B-139, Research Center 2 Room 8005, Aurora, CO 80045, USA.
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8
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OUP accepted manuscript. Eur J Cardiothorac Surg 2022; 62:6527516. [DOI: 10.1093/ejcts/ezac032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 12/06/2021] [Accepted: 01/11/2022] [Indexed: 11/14/2022] Open
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9
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Costanzo MR, O'Connor CM, Ventura HO. Advanced Heart Failure: Progress and Disappointments. JACC. HEART FAILURE 2021; 9:938-940. [PMID: 34857178 DOI: 10.1016/j.jchf.2021.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
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10
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Kapelios CJ, Canepa M, Benson L, Hage C, Thorvaldsen T, Dahlström U, Savarese G, Lund LH. Non-cardiology vs. cardiology care of patients with heart failure and reduced ejection fraction is associated with lower use of guideline-based care and higher mortality: Observations from The Swedish Heart Failure Registry. Int J Cardiol 2021; 343:63-72. [PMID: 34517016 DOI: 10.1016/j.ijcard.2021.09.013] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 08/19/2021] [Accepted: 09/07/2021] [Indexed: 01/09/2023]
Abstract
BACKGROUND Patients with heart failure (HF) are often cared for by non-cardiologists. The implications are unknown. METHODS In a nationwide HF cohort with reduced ejection fraction (HFrEF), we compared demographics, clinical characteristics, guideline-based therapy use and outcomes in non-cardiology vs. cardiology in-patient and out-patient care. RESULTS Between 2000 and 2016, 36,076 patients with HFrEF were enrolled in the Swedish HF registry (19,337 [54%] in-patients overall), with 44% of in-patients and 45% of out-patients managed in non-cardiology settings. Predictors of treatment in non-cardiology were age > 75 years (adjusted odds ratio for non-cardiology 1.20; 95% confidence interval 1.14-1.27), lower education level (0.71; 0.66-0.76 for university vs. compulsory), valve disease (1.24; 1.18-1.31) and systolic blood pressure (SBP) >120 mmHg (1.05; 1.00-1.10). Non-cardiology care was significantly associated with lower use of beta-blockers (0.80; 0.74-0.86) and devices (intracardiac defibrillator [ICD] and/or cardiac resynchronization therapy [CRT]: 0.63; 0.56-0.71), and less frequent specialist follow-up (0.61; 0.57-0.65). Over 1-year follow-up the risk of all-cause mortality (adjusted hazard ratio 1.09; 1.03-1.15) was higher but the risk of first HF (re-) hospitalization was lower (0.93; 0.89-0.97) in non-cardiology vs. cardiology care. CONCLUSIONS In HFrEF, non-cardiology care was independently associated with older ageand lower education. After covariate adjustment, non-cardiology care was associated with lower use of beta-blockers and devices, higher mortality, and lower risk of HF hospitalization. Access to cardiology care may not be equitable and this may have implications for use of guideline-based care and outcomes.
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Affiliation(s)
| | - Marco Canepa
- Cardiology Unit, Department of Internal Medicine, University of Genoa, Italy; Ospedale Policlinico San Martino IRCCS, Genoa, Italy
| | - Lina Benson
- Unit of Cardiology, Department of Medicine, Karolinska Institutet, Sweden
| | - Camilla Hage
- Unit of Cardiology, Department of Medicine, Karolinska Institutet, and Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Tonje Thorvaldsen
- Unit of Cardiology, Department of Medicine, Karolinska Institutet, and Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Ulf Dahlström
- Department of Cardiology, Linkoping University, Linkoping, Sweden; Department of Health, Medicine and Caring Sciences, Linkoping University, Linkoping, Sweden
| | - Gianluigi Savarese
- Unit of Cardiology, Department of Medicine, Karolinska Institutet, and Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Lars H Lund
- Unit of Cardiology, Department of Medicine, Karolinska Institutet, and Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden.
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Abstract
Left ventricular assist devices (LVADs) are indicated in inotrope-dependent heart failure (HF) patients with pure or predominant LV dysfunction. Survival benefit is less clear in ambulatory, advanced HF. Timing is crucial: early, unnecessary exposure to the risks of surgery, and device-related complications (infections, stroke, and bleeding) should be weighed against the probability of dying or developing irreversible right ventricular and/or end-organ dysfunction while deferring implant. The interplay between LVAD and heart transplantation depends largely on donor availability and allocation rules. Postoperatively, quality of life depends on patients' expectations and is influenced by complications. Patients' preferences, prognosis, and alternative options-including palliation-should be openly discussed and reviewed before and after the operation.
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Affiliation(s)
- Maria Frigerio
- 2nd Section of Cardiology, Heart Failure and Transplant Unit, DeGasperis CardioCenter, Niguarda Great Metropolitan Hospital, Milan, Italy.
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12
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Hsu CH, Tung HH, Wu YC, Wei J, Tsay SL. Demoralization syndrome among cardiac transplant recipients. J Clin Nurs 2021; 31:2271-2286. [PMID: 34523181 DOI: 10.1111/jocn.16045] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Revised: 06/13/2021] [Accepted: 07/15/2021] [Indexed: 11/28/2022]
Abstract
AIMS AND OBJECTIVES To investigate the characteristics and prevalence of demoralisation syndrome among heart transplantation patients in Taiwan. BACKGROUND Patients with end-stage heart failure who have undergone cardiac transplantation are at risk of demoralisation syndrome. Demoralisation syndrome has been studied in cancer populations, but our understanding of the syndrome among heart transplant recipients is limited. DESIGN AND METHODS The study adopted a cross-sectional design and analysed the baseline data from a longitudinal study with cardiac transplant patients at a heart centre in northern Taiwan. A structured questionnaire, namely the Demoralization Scale-Mandarin Version (DS-MV), was used to assess demoralisation syndrome. Hierarchical regression was applied to determine the predictors of demoralisation. Reporting was consistent with the STROBE checklist. RESULTS There were a total of 84 participants with an average age of 51.9 years and a time since heart transplantation of around 4.1 years. Among them, the prevalence of demoralisation syndrome was 35.8%, and 57.1% coped well with stress. In addition, on the DS-MV, participants tended to choose sentences with positive rather than negative wording. Our data showed that cardiac transplant recipients with stress have higher possibility suffering from demoralisation syndrome; poor renal function and those who cannot relive from stress are predictors for loss of meaning. CONCLUSIONS Chinese individuals tend to hide their weaknesses; nevertheless, demoralisation syndrome among cardiac transplant recipients, as related to stress status and kidney function, is still remarkable. RELEVANCE TO CLINICAL PRACTICE Since demoralisation is preventable, further research on this phenomenon in the cardiac transplant population is warranted and needs to be developed.
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Affiliation(s)
- Ching-Hwa Hsu
- College of Nursing, National Yang Ming Chiao Tung University, Heart Center of Cheng-Hsin General Hospital, Taipei, Taiwan
| | - Heng-Hsin Tung
- College of Nursing, National Yang Ming Chiao Tung University, Tungs' Taichung MetroHarbor Hospital, Taipei, Taiwan
| | - Yi-Chen Wu
- College of Nursing, National Yang Ming Chiao Tung University, Fu Jen Catholic University Hospital, Fu Jen Catholic University, New Taipei City, Taiwan
| | - Jeng Wei
- Heart Center of Cheng-Hsin General Hospital, Taipei, Taiwan
| | - Shiow-Luan Tsay
- College of Nursing and Health Sciences, Da-Yeh University, Changhua, Taiwan
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13
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Baudry G, Nesseler N, Flecher E, Vincentelli A, Goeminne C, Delmas C, Porterie J, Nubret K, Pernot M, Kindo M, Hoang Minh T, Rouvière P, Gaudard P, Michel M, Senage T, Boignard A, Chavanon O, Para M, Verdonk C, Pelcé E, Gariboldi V, Anselme F, Litzler PY, Blanchart K, Babatasi G, Bielefeld M, Bouchot O, Hamon D, Lellouche N, Bailleul X, Genet T, Eschalier R, d'Ostrevy N, Bories MC, Akar RA, Blangy H, Vanhuyse F, Obadia JF, Galand V, Pozzi M. Characteristics and outcome of ambulatory heart failure patients receiving a left ventricular assist device. ESC Heart Fail 2021; 8:5159-5167. [PMID: 34494391 PMCID: PMC8712824 DOI: 10.1002/ehf2.13592] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 07/12/2021] [Accepted: 08/19/2021] [Indexed: 02/04/2023] Open
Abstract
Aims Despite regularly updated guidelines, there is still a delay in referral of advanced heart failure patients to mechanical circulatory support and transplant centres. We aimed to analyse characteristics and outcome of non‐inotrope‐dependent patients implanted with a left ventricular assist device (LVAD). Methods and results The ASSIST‐ICD registry collected LVAD data in 19 centres in France between February 2006 and December 2016. We used data of patients in Interagency Registry for Mechanically Assisted Circulatory Support Classes 4–7. The primary endpoint was survival analysis. Predictors of mortality were searched with multivariable analyses. A total of 303 patients (mean age 61.0 ± 9.9 years, male sex 86.8%) were included in the present analysis. Ischaemic cardiomyopathy was the leading heart failure aetiology (64%), and bridge to transplantation was the main implantation strategy (56.1%). The overall likelihood of being alive while on LVAD support or having a transplant at 1, 2, 3, and 5 years was 66%, 61.7%, 58.7%, and 55.1%, respectively. Age [hazard ratio (HR) 1.03, 95% confidence interval (CI) 1.00–1.05; P = 0.02], a concomitant procedure (HR 2.32, 95% CI 1.52–3.53; P < 0.0001), and temporary mechanical right ventricular support during LVAD implantation (HR 2.94, 95% CI 1.49–5.77; P = 0.002) were the only independent variables associated with mortality. Heart failure medications before or after LVAD implantation were not associated with survival. Conclusion Ambulatory heart failure patients displayed unsatisfactory survival rates after LVAD implantation. A better selection of patients who can benefit from LVAD may help improving outcomes.
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Affiliation(s)
- Guillaume Baudry
- Heart Failure Unit, Hospices Civils de Lyon, Louis Pradel Hospital, Lyon, France
| | | | - Erwan Flecher
- Univ Rennes, CHU Rennes, INSERM, LTSI-UMR 1099, Rennes, France
| | - André Vincentelli
- Cardiac Intensive Care Unit, Department of Cardiology, Department of Cardiac Surgery, CHU Lille, Institut Coeur-Poumons, Lille, France
| | - Céline Goeminne
- Cardiac Intensive Care Unit, Department of Cardiology, Department of Cardiac Surgery, CHU Lille, Institut Coeur-Poumons, Lille, France
| | - Clément Delmas
- Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - Jean Porterie
- Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - Karine Nubret
- Hôpital Cardiologique du Haut-Lévêque, Université Bordeaux II, Bordeaux, France
| | - Mathieu Pernot
- Hôpital Cardiologique du Haut-Lévêque, Université Bordeaux II, Bordeaux, France
| | - Michel Kindo
- Département de Chirurgie Cardiovasculaire, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Tam Hoang Minh
- Département de Chirurgie Cardiovasculaire, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Philippe Rouvière
- Department of Cardiac Surgery, Anesthesiology and Critical Care Medicine, Arnaud de Villeneuve Hospital, CHRU Montpellier, Montpellier, France
| | - Philippe Gaudard
- Department of Cardiac Surgery, Anesthesiology and Critical Care Medicine, Arnaud de Villeneuve Hospital, CHRU Montpellier, Montpellier, France
| | - Magali Michel
- Department of Cardiology and Heart Transplantation Unit, CHU Nantes, Nantes, France
| | - Thomas Senage
- Department of Cardiology and Heart Transplantation Unit, CHU Nantes, Nantes, France
| | - Aude Boignard
- Department of Cardiology and Cardiovascular Surgery, CHU Michallon, Grenoble, France
| | - Olivier Chavanon
- Department of Cardiology and Cardiovascular Surgery, CHU Michallon, Grenoble, France
| | - Marylou Para
- Department of Cardiac Surgery and Cardiology, Bichat-Hospital, Paris, France
| | - Constance Verdonk
- Department of Cardiac Surgery and Cardiology, Bichat-Hospital, Paris, France
| | - Edeline Pelcé
- Department of Cardiac Surgery, La Timone Hospital, Marseille, France
| | - Vlad Gariboldi
- Department of Cardiac Surgery, La Timone Hospital, Marseille, France
| | - Frederic Anselme
- Department of Cardiology and Cardiovascular Surgery, Hospital Charles Nicolle, Rouen, France
| | - Pierre-Yves Litzler
- Department of Cardiology and Cardiovascular Surgery, Hospital Charles Nicolle, Rouen, France
| | - Katrien Blanchart
- Department of Cardiology and Cardiac Surgery, University of Caen and University Hospital of Caen, Caen, France
| | - Gerard Babatasi
- Department of Cardiology and Cardiac Surgery, University of Caen and University Hospital of Caen, Caen, France
| | - Marie Bielefeld
- Department of Cardiology and Cardiac Surgery, University Hospital, Dijon, Dijon, France
| | - Olivier Bouchot
- Department of Cardiology and Cardiac Surgery, University Hospital, Dijon, Dijon, France
| | - David Hamon
- Department of Cardiology, AP-HP CHU Henri Mondor, Créteil, France
| | | | - Xavier Bailleul
- Cardiac Surgery Department and Cardiology Department, Cardiac Intensive Care Unit, Tours University Hospital, Tours, France
| | - Thibaud Genet
- Cardiac Surgery Department and Cardiology Department, Cardiac Intensive Care Unit, Tours University Hospital, Tours, France
| | - Romain Eschalier
- Cardiology and Cardiac Surgery Department, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Nicolas d'Ostrevy
- Cardiology and Cardiac Surgery Department, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Marie-Cécile Bories
- Cardiology and Cardiac Surgery Department, European Georges Pompidou Hospital, Paris, France
| | - Ramzi Abi Akar
- Cardiology and Cardiac Surgery Department, European Georges Pompidou Hospital, Paris, France
| | - Hugues Blangy
- Department of Cardiology and Cardiac Surgery, CHU de Nancy, Hopital de Brabois, Nancy, France
| | - Fabrice Vanhuyse
- Department of Cardiology and Cardiac Surgery, CHU de Nancy, Hopital de Brabois, Nancy, France
| | - Jean François Obadia
- Department of Cardiology and Cardiac Surgery, Hospices Civils de Lyon, Louis Pradel Hospital, Lyon, France
| | - Vincent Galand
- Univ Rennes, CHU Rennes, INSERM, LTSI-UMR 1099, Rennes, France
| | - Matteo Pozzi
- Department of Cardiology and Cardiac Surgery, Hospices Civils de Lyon, Louis Pradel Hospital, Lyon, France
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14
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Larsson J, Kristensen SL, Madelaire C, Schou M, Rossing K, Boesgaard S, Køber L, Gustafsson F. Socioeconomic Disparities in Referral for Invasive Hemodynamic Evaluation for Advanced Heart Failure: A Nationwide Cohort Study. Circ Heart Fail 2021; 14:e008662. [PMID: 34461745 DOI: 10.1161/circheartfailure.121.008662] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Factors determining referral for advanced heart failure (HF) evaluation are poorly studied. We studied the influence of socioeconomic aspects on the referral process in Denmark, which has a taxpayer-funded national health care system. METHODS We identified all patients aged 18 to 75 years with a first diagnosis of HF during 2010 to 2018. Hospitalized patients had to be discharged alive and were then followed for the outcome of undergoing a right heart catheterization (RHC) used as a surrogate marker of advanced HF work-up. RESULTS Of 36 637 newly diagnosed patients with HF, 680 (1.9%) underwent RHC during the follow-up period (median time to RHC of 280 days [interquartile range, 73-914]). Factors associated with a higher likelihood of RHC included the highest versus lowest household income quartile (HR, 1.56 [95% CI, 1.19-2.06]; P=0.001), being diagnosed with HF at a tertiary versus nontertiary hospital (HR, 1.68 [95% CI, 1.37-2.05]; P<0.001) and during a hospitalization versus outpatient visit (HR, 1.67 [95% CI, 1.42-1.95]; P<0.001). Level of education, occupational status, and distance to tertiary hospital were not independently associated with RHC. Older age, cancer, and a psychiatric diagnosis were independently associated with a decreased probability of RHC. CONCLUSIONS Higher household income, HF diagnosis during hospitalization, and first admission at a tertiary hospital were associated with increased likelihood of subsequent referral for RHC independent of other demographic and clinical variables. Greater attention may be required to ensure timely referral for advanced HF therapies in lower income groups.
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Affiliation(s)
- Johan Larsson
- Department of Cardiology, Rigshospitalet University Hospital, Copenhagen, Denmark (J.L., S.L.K., K.R., S.B., L.K., F.G.)
| | - Søren L Kristensen
- Department of Cardiology, Rigshospitalet University Hospital, Copenhagen, Denmark (J.L., S.L.K., K.R., S.B., L.K., F.G.)
| | | | - Morten Schou
- Department of Cardiology, Herlev and Gentofte Hospital, Copenhagen, Denmark (M.S.)
| | - Kasper Rossing
- Department of Cardiology, Rigshospitalet University Hospital, Copenhagen, Denmark (J.L., S.L.K., K.R., S.B., L.K., F.G.)
| | - Søren Boesgaard
- Department of Cardiology, Rigshospitalet University Hospital, Copenhagen, Denmark (J.L., S.L.K., K.R., S.B., L.K., F.G.)
| | - Lars Køber
- Department of Cardiology, Rigshospitalet University Hospital, Copenhagen, Denmark (J.L., S.L.K., K.R., S.B., L.K., F.G.)
| | - Finn Gustafsson
- Department of Cardiology, Rigshospitalet University Hospital, Copenhagen, Denmark (J.L., S.L.K., K.R., S.B., L.K., F.G.)
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15
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Mullens W, Auricchio A, Martens P, Witte K, Cowie MR, Delgado V, Dickstein K, Linde C, Vernooy K, Leyva F, Bauersachs J, Israel CW, Lund LH, Donal E, Boriani G, Jaarsma T, Berruezo A, Traykov V, Yousef Z, Kalarus Z, Nielsen JC, Steffel J, Vardas P, Coats A, Seferovic P, Edvardsen T, Heidbuchel H, Ruschitzka F, Leclercq C. Optimized implementation of cardiac resynchronization therapy: a call for action for referral and optimization of care. Europace 2021; 23:1324-1342. [PMID: 34037728 DOI: 10.1093/europace/euaa411] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 10/28/2020] [Accepted: 10/29/2020] [Indexed: 12/28/2022] Open
Abstract
Cardiac resynchronization therapy (CRT) is one of the most effective therapies for heart failure with reduced ejection fraction and leads to improved quality of life, reductions in heart failure hospitalization rates and all-cause mortality. Nevertheless, up to two-thirds of eligible patients are not referred for CRT. Furthermore, post-implantation follow-up is often fragmented and suboptimal, hampering the potential maximal treatment effect. This joint position statement from three European Society of Cardiology Associations, Heart Failure Association (HFA), European Heart Rhythm Association (EHRA) and European Association of Cardiovascular Imaging (EACVI), focuses on optimized implementation of CRT. We offer theoretical and practical strategies to achieve more comprehensive CRT referral and post-procedural care by focusing on four actionable domains: (i) overcoming CRT under-utilization, (ii) better understanding of pre-implant characteristics, (iii) abandoning the term 'non-response' and replacing this by the concept of disease modification, and (iv) implementing a dedicated post-implant CRT care pathway.
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Affiliation(s)
- Wilfried Mullens
- Ziekenhuis Oost Limburg, Genk, Belgium
- University Hasselt, Hasselt, Belgium
| | - Angelo Auricchio
- Division of Cardiology, Cardiocentro Ticino, Lugano, Switzerland
| | - Pieter Martens
- Ziekenhuis Oost Limburg, Genk, Belgium
- University Hasselt, Hasselt, Belgium
| | - Klaus Witte
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Martin R Cowie
- Imperial College London (Royal Brompton Hospital), London, UK
| | - Victoria Delgado
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Cecilia Linde
- Heart and Vascular Theme, Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden
| | - Kevin Vernooy
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands
- Department of Cardiology, Radboud University Medical Center (Radboudumc), Nijmegen, The Netherlands
| | | | - Johann Bauersachs
- Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Carsten W Israel
- Department of Medicine - Cardiology, Diabetology and Nephrology, Bethel-Clinic, Bielefeld, Germany
| | - Lars H Lund
- Department of Medicine Karolinska Institutet, and Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
| | - Erwan Donal
- Cardiologie, CHU Rennes - LTSI Inserm UMR 1099, Université Rennes-1, Rennes, France
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Tiny Jaarsma
- Julius Center, University Medical Center Utrecht, Utrecht, The Netherlands
- Department of Health, Medicine and Caring Science, Linköping University, Linköping, Sweden
| | | | - Vassil Traykov
- Department of Cardiology, Acibadem City Clinic Tokuda Hospital, Sofia, Bulgaria
| | - Zaheer Yousef
- Department of Cardiology, University Hospital of Wales & Cardiff University, Cardiff, UK
| | - Zbigniew Kalarus
- Department of Cardiology, Medical University of Silesia, Katowice, Poland
| | | | - Jan Steffel
- UniversitätsSpital Zürich, Zürich, Switzerland
| | - Panos Vardas
- Heart Sector, Hygeia Hospitals Group, Athens, Greece
| | | | - Petar Seferovic
- Faculty of Medicine, Serbian Academy of Science and Arts, Belgrade University, Belgrade, Serbia
| | - Thor Edvardsen
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, and University of Oslo, Oslo, Norway
| | - Hein Heidbuchel
- Antwerp University and Antwerp University Hospital, Antwerp, Belgium
| | - Frank Ruschitzka
- Department of Cardiology, University Hospital, University Heart Center, Zurich, Switzerland
| | - Christophe Leclercq
- Cardiologie, CHU Rennes - LTSI Inserm UMR 1099, Université Rennes-1, Rennes, France
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16
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Fowokan A, Frankfurter C, Dobrow MJ, Abrahamyan L, Mcdonald M, Virani S, Harkness K, Lee DS, Pakosh M, Ross H, Grace SL. Referral and access to heart function clinics: A realist review. J Eval Clin Pract 2021; 27:949-964. [PMID: 33020996 DOI: 10.1111/jep.13489] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 08/27/2020] [Accepted: 09/04/2020] [Indexed: 12/24/2022]
Abstract
RATIONALE, AIM, AND OBJECTIVES Heart failure (HF) clinics are highly effective, yet not optimally utilized. A realist review was performed to identify contexts (eg, health system characteristics, clinic capacity, and siting) and underlying mechanisms (eg, referring provider knowledge of clinics and referral criteria, barriers in disadvantaged patients) that influence utilization (provider referral [ie, of all appropriate and no inappropriate patients] and access [ie, patient attends ≥1 visit]) of HF clinics. METHODS Following an initial scoping search and field observation in a HF clinic, we developed an initial program theory in conjunction with our expert panel, which included patient partners. Then, a literature search of seven databases was searched from inception to December 2019, including Medline; Grey literature was also searched. Studies of any design or editorials were included; studies regarding access to cardiac rehabilitation, or a single specialist for example, were excluded. Two independent reviewers screened the abstracts, and then full-texts. Relevant data from included articles were used to refine the program theory. RESULTS A total of 29 papers from five countries (three regions) were included. There was limited information to support or refute many elements of our initial program theory (eg, referring provider knowledge/beliefs, clinic inclusion/exclusion criteria), but refinements were made (eg, specialized care provided in each clinic, lack of patient encouragement). Lack of capacity, geography, and funding arrangements were identified as contextual factors, explaining a range of mechanistic processes, including patient clinical characteristics and social determinants of health as well as clinic characteristics that help to explain inappropriate and low use of HF clinics (outcome). CONCLUSION Given the burden of HF and benefit of HF clinics, more research is needed to understand, and hence overcome sub-optimal use of HF clinics. In particular, an understanding from the perspective of referring providers is needed.
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Affiliation(s)
| | | | - Mark J Dobrow
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Lusine Abrahamyan
- University Health Network, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | | | - Sean Virani
- St. Paul's Hospital, University of British Columbia, and Cardiac Services BC, Vancouver, British Columbia, Canada
| | - Karen Harkness
- CorHealth Ontario, Toronto, Ontario, Canada.,School of Nursing, McMaster University, Hamilton, Ontario, Canada
| | - Douglas S Lee
- University Health Network, Toronto, Ontario, Canada.,Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,ICES, Toronto, Ontario, Canada
| | - Maureen Pakosh
- Library & Information Services, University Health Network, Toronto, Ontario, Canada
| | - Heather Ross
- University Health Network, Toronto, Ontario, Canada
| | - Sherry L Grace
- University Health Network, Toronto, Ontario, Canada.,Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Faculty of Health, York University, Toronto, Ontario, Canada
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17
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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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18
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Khatana SAM, Hanff TC, Nathan AS, Dayoub EJ, Grandin EW, Rame JE, Fanaroff AC, Giri J, Groeneveld PW. Association of Health Insurance Payer Type and Outcomes After Durable Left Ventricular Assist Device Implantation: An Analysis of the STS-INTERMACS Registry. Circ Heart Fail 2021; 14:e008277. [PMID: 33993721 DOI: 10.1161/circheartfailure.120.008277] [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] [Indexed: 11/16/2022]
Abstract
BACKGROUND Due to the high cost of left ventricular assist device (LVAD) therapy, payer type may be an important factor in determining eligibility. How payer type influences outcomes after LVAD implantation is unclear. We, therefore, aimed to study the association of health insurance payer type with outcomes after durable LVAD implantation. METHODS Using STS-INTERMACS (Society of Thoracic Surgeons-Interagency Registry for Mechanically Assisted Circulatory Support), we studied nonelderly adults receiving a durable LVAD from 2016 to 2018 and compared all-cause mortality and postindex hospitalization adverse event episode rate by payer type. Multivariable Fine-Gray and generalized linear models were used to compare the outcomes. RESULTS Of the 3251 patients included, 26.0% had Medicaid, 24.9% had Medicare alone, and 49.1% had commercial insurance. Compared with commercially insured patients, mortality did not differ for patients with Medicaid (subdistribution hazard ratio, 1.00 [95% CI, 0.75-1.34], P=0.99) or Medicare (subdistribution hazard ratio, 1.09 [95% CI, 0.84-1.41], P=0.52). Medicaid was associated with a significantly lower adjusted incidence rate (incidence rate ratio, 0.88 [95% CI, 0.78-0.99], P=0.041), and Medicare was associated with a significantly higher adjusted incidence rate (incidence rate ratio, 1.16 [95% CI, 1.03-1.30], P=0.011) of adverse event episodes compared with commercially insured patients. CONCLUSIONS All-cause mortality after durable LVAD implantation did not differ significantly by payer type. Payer type was associated with the rate of adverse events, with Medicaid associated with a significantly lower rate, and Medicare with a significantly higher rate of adverse event episodes compared with commercially insured patients.
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Affiliation(s)
- Sameed Ahmed M Khatana
- Division of Cardiovascular Medicine (S.A.M.K., T.C.H., A.S.N., E.J.D., A.C.F., J.G.), Perelman School of Medicine, University of Pennsylvania, PA.,Penn Cardiovascular Outcomes, Quality, & Evaluative Research Center (S.A.M.K., T.C.H., A.S.N., E.J.D., A.C.F., J.G., P.W.G.), Perelman School of Medicine, University of Pennsylvania, PA.,The Leonard Davis Institute of Health Economics (S.A.M.K., A.S.N., E.J.D., A.C.F., J.G., P.W.G.), Perelman School of Medicine, University of Pennsylvania, PA
| | - Thomas C Hanff
- Division of Cardiovascular Medicine (S.A.M.K., T.C.H., A.S.N., E.J.D., A.C.F., J.G.), Perelman School of Medicine, University of Pennsylvania, PA.,Penn Cardiovascular Outcomes, Quality, & Evaluative Research Center (S.A.M.K., T.C.H., A.S.N., E.J.D., A.C.F., J.G., P.W.G.), Perelman School of Medicine, University of Pennsylvania, PA
| | - Ashwin S Nathan
- Division of Cardiovascular Medicine (S.A.M.K., T.C.H., A.S.N., E.J.D., A.C.F., J.G.), Perelman School of Medicine, University of Pennsylvania, PA.,Penn Cardiovascular Outcomes, Quality, & Evaluative Research Center (S.A.M.K., T.C.H., A.S.N., E.J.D., A.C.F., J.G., P.W.G.), Perelman School of Medicine, University of Pennsylvania, PA.,The Leonard Davis Institute of Health Economics (S.A.M.K., A.S.N., E.J.D., A.C.F., J.G., P.W.G.), Perelman School of Medicine, University of Pennsylvania, PA
| | - Elias J Dayoub
- Division of Cardiovascular Medicine (S.A.M.K., T.C.H., A.S.N., E.J.D., A.C.F., J.G.), Perelman School of Medicine, University of Pennsylvania, PA.,Penn Cardiovascular Outcomes, Quality, & Evaluative Research Center (S.A.M.K., T.C.H., A.S.N., E.J.D., A.C.F., J.G., P.W.G.), Perelman School of Medicine, University of Pennsylvania, PA.,The Leonard Davis Institute of Health Economics (S.A.M.K., A.S.N., E.J.D., A.C.F., J.G., P.W.G.), Perelman School of Medicine, University of Pennsylvania, PA
| | - E Wilson Grandin
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology (E.W.G.), Beth Israel Deaconess Medical Center, Boston, MA.,Division of Cardiology (E.W.G.), Beth Israel Deaconess Medical Center, Boston, MA
| | - J Eduardo Rame
- Jefferson Heart Institute, Thomas Jefferson University Hospital, Pennsylvania, PA (J.E.R.)
| | - Alexander C Fanaroff
- Division of Cardiovascular Medicine (S.A.M.K., T.C.H., A.S.N., E.J.D., A.C.F., J.G.), Perelman School of Medicine, University of Pennsylvania, PA.,Penn Cardiovascular Outcomes, Quality, & Evaluative Research Center (S.A.M.K., T.C.H., A.S.N., E.J.D., A.C.F., J.G., P.W.G.), Perelman School of Medicine, University of Pennsylvania, PA.,The Leonard Davis Institute of Health Economics (S.A.M.K., A.S.N., E.J.D., A.C.F., J.G., P.W.G.), Perelman School of Medicine, University of Pennsylvania, PA
| | - Jay Giri
- Division of Cardiovascular Medicine (S.A.M.K., T.C.H., A.S.N., E.J.D., A.C.F., J.G.), Perelman School of Medicine, University of Pennsylvania, PA.,Penn Cardiovascular Outcomes, Quality, & Evaluative Research Center (S.A.M.K., T.C.H., A.S.N., E.J.D., A.C.F., J.G., P.W.G.), Perelman School of Medicine, University of Pennsylvania, PA.,The Leonard Davis Institute of Health Economics (S.A.M.K., A.S.N., E.J.D., A.C.F., J.G., P.W.G.), Perelman School of Medicine, University of Pennsylvania, PA
| | - Peter W Groeneveld
- Penn Cardiovascular Outcomes, Quality, & Evaluative Research Center (S.A.M.K., T.C.H., A.S.N., E.J.D., A.C.F., J.G., P.W.G.), Perelman School of Medicine, University of Pennsylvania, PA.,The Leonard Davis Institute of Health Economics (S.A.M.K., A.S.N., E.J.D., A.C.F., J.G., P.W.G.), Perelman School of Medicine, University of Pennsylvania, PA.,Division of General Internal Medicine, Perelman School of Medicine (P.W.G.), Perelman School of Medicine, University of Pennsylvania, PA.,Center for Health Equity Research and Promotion, Michael J. Crescenz Veterans Affairs Medical Center, Pennsylvania, PA (P.W.G.)
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19
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Mullens W, Auricchio A, Martens P, Witte K, Cowie MR, Delgado V, Dickstein K, Linde C, Vernooy K, Leyva F, Bauersachs J, Israel CW, Lund LH, Donal E, Boriani G, Jaarsma T, Berruezo A, Traykov V, Yousef Z, Kalarus Z, Cosedis Nielsen J, Steffel J, Vardas P, Coats A, Seferovic P, Edvardsen T, Heidbuchel H, Ruschitzka F, Leclercq C. Optimized implementation of cardiac resynchronization therapy: a call for action for referral and optimization of care: A joint position statement from the Heart Failure Association (HFA), European Heart Rhythm Association (EHRA), and European Association of Cardiovascular Imaging (EACVI) of the European Society of Cardiology. Eur J Heart Fail 2021; 22:2349-2369. [PMID: 33136300 DOI: 10.1002/ejhf.2046] [Citation(s) in RCA: 100] [Impact Index Per Article: 33.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 10/28/2020] [Accepted: 10/29/2020] [Indexed: 12/28/2022] Open
Abstract
Cardiac resynchronization therapy (CRT) is one of the most effective therapies for heart failure with reduced ejection fraction and leads to improved quality of life, reductions in heart failure hospitalization rates and all-cause mortality. Nevertheless, up to two-thirds of eligible patients are not referred for CRT. Furthermore, post-implantation follow-up is often fragmented and suboptimal, hampering the potential maximal treatment effect. This joint position statement from three European Society of Cardiology Associations, Heart Failure Association (HFA), European Heart Rhythm Association (EHRA) and European Association of Cardiovascular Imaging (EACVI), focuses on optimized implementation of CRT. We offer theoretical and practical strategies to achieve more comprehensive CRT referral and post-procedural care by focusing on four actionable domains: (i) overcoming CRT under-utilization, (ii) better understanding of pre-implant characteristics, (iii) abandoning the term 'non-response' and replacing this by the concept of disease modification, and (iv) implementing a dedicated post-implant CRT care pathway.
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Affiliation(s)
- Wilfried Mullens
- Ziekenhuis Oost Limburg, Genk, Belgium.,University Hasselt, Hasselt, Belgium
| | - Angelo Auricchio
- Division of Cardiology, Cardiocentro Ticino, Lugano, Switzerland
| | - Pieter Martens
- Ziekenhuis Oost Limburg, Genk, Belgium.,University Hasselt, Hasselt, Belgium
| | - Klaus Witte
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Martin R Cowie
- Imperial College London (Royal Brompton Hospital), London, UK
| | - Victoria Delgado
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Cecilia Linde
- Heart and Vascular Theme, Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden
| | - Kevin Vernooy
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands.,Department of Cardiology, Radboud University Medical Center (Radboudumc), Nijmegen, The Netherlands
| | | | - Johann Bauersachs
- Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Carsten W Israel
- Department of Medicine - Cardiology, Diabetology and Nephrology, Bethel-Clinic, Bielefeld, Germany
| | - Lars H Lund
- Department of Medicine Karolinska Institutet, and Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
| | - Erwan Donal
- Cardiologie, CHU Rennes - LTSI Inserm UMR 1099, Université Rennes-1, Rennes, France
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Tiny Jaarsma
- Julius Center, University Medical Center Utrecht, Utrecht, The Netherlands.,Department of Health, Medicine and Caring Science, Linköping University, Linköping, Sweden
| | | | - Vassil Traykov
- Department of Cardiology, Acibadem City Clinic Tokuda Hospital, Sofia, Bulgaria
| | - Zaheer Yousef
- Department of Cardiology, University Hospital of Wales & Cardiff University, Cardiff, UK
| | - Zbigniew Kalarus
- Department of Cardiology, Medical University of Silesia, Katowice, Poland
| | | | - Jan Steffel
- UniversitätsSpital Zürich, Zürich, Switzerland
| | - Panos Vardas
- Heart Sector, Hygeia Hospitals Group, Athens, Greece
| | | | - Petar Seferovic
- Faculty of Medicine, Serbian Academy of Science and Arts, Belgrade University, Belgrade, Serbia
| | - Thor Edvardsen
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, and University of Oslo, Oslo, Norway
| | - Hein Heidbuchel
- Antwerp University and Antwerp University Hospital, Antwerp, Belgium
| | - Frank Ruschitzka
- Department of Cardiology, University Hospital, University Heart Center, Zurich, Switzerland
| | - Christophe Leclercq
- Cardiologie, CHU Rennes - LTSI Inserm UMR 1099, Université Rennes-1, Rennes, France
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20
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Coats AJS, Anker SD, Baumbach A, Alfieri O, von Bardeleben RS, Bauersachs J, Bax JJ, Boveda S, Čelutkienė J, Cleland JG, Dagres N, Deneke T, Farmakis D, Filippatos G, Hausleiter J, Hindricks G, Jankowska EA, Lainscak M, Leclercq C, Lund LH, McDonagh T, Mehra MR, Metra M, Mewton N, Mueller C, Mullens W, Muneretto C, Obadia JF, Ponikowski P, Praz F, Rudolph V, Ruschitzka F, Vahanian A, Windecker S, Zamorano JL, Edvardsen T, Heidbuchel H, Seferovic PM, Prendergast B. The management of secondary mitral regurgitation in patients with heart failure: a joint position statement from the Heart Failure Association (HFA), European Association of Cardiovascular Imaging (EACVI), European Heart Rhythm Association (EHRA), and European Association of Percutaneous Cardiovascular Interventions (EAPCI) of the ESC. Eur Heart J 2021; 42:1254-1269. [PMID: 33734354 PMCID: PMC8014526 DOI: 10.1093/eurheartj/ehab086] [Citation(s) in RCA: 78] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 01/01/2021] [Accepted: 02/21/2021] [Indexed: 02/06/2023] Open
Abstract
Secondary (or functional) mitral regurgitation (SMR) occurs frequently in chronic heart failure (HF) with reduced left ventricular (LV) ejection fraction, resulting from LV remodelling that prevents coaptation of the valve leaflets. Secondary mitral regurgitation contributes to progression of the symptoms and signs of HF and confers worse prognosis. The management of HF patients with SMR is complex and requires timely referral to a multidisciplinary Heart Team. Optimization of pharmacological and device therapy according to guideline recommendations is crucial. Further management requires careful clinical and imaging assessment, addressing the anatomical and functional features of the mitral valve and left ventricle, overall HF status, and relevant comorbidities. Evidence concerning surgical correction of SMR is sparse and it is doubtful whether this approach improves prognosis. Transcatheter repair has emerged as a promising alternative, but the conflicting results of current randomized trials require careful interpretation. This collaborative position statement, developed by four key associations of the European Society of Cardiology-the Heart Failure Association (HFA), European Association of Percutaneous Cardiovascular Interventions (EAPCI), European Association of Cardiovascular Imaging (EACVI), and European Heart Rhythm Association (EHRA)-presents an updated practical approach to the evaluation and management of patients with HF and SMR based upon a Heart Team approach.
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Affiliation(s)
| | - Stefan D Anker
- Department of Cardiology (CVK), Germany.,Berlin Institute of Health Center for Regenerative Therapies (BCRT), Germany.,German Centre for Cardiovascular Research (DZHK) partner site Berlin, Germany.,Charité Universitätsmedizin Berlin, Germany
| | - Andreas Baumbach
- Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London, and Yale University School of Medicine, New Haven, USA
| | - Ottavio Alfieri
- Department of Cardiac Surgery, San Raffaele Scientific Institute, Milan, Italy
| | | | - Johann Bauersachs
- Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Jeroen J Bax
- Department of Cardiology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Serge Boveda
- Department of Cardiology, Clinique Pasteur, 31076 Toulouse, France
| | - Jelena Čelutkienė
- Clinic of Cardiac and Vascular Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania.,State Research Institute Centre For Innovative Medicine, Vilnius, Lithuania
| | - John G Cleland
- Robertson Centre for Biostatistics & Clinical Trials, University of Glasgow, Glasgow, UK
| | - Nikolaos Dagres
- Department of Electrophysiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | - Thomas Deneke
- Heart Center Bad Neustadt, Clinic for Interventional Electrophysiology, Germany
| | | | - Gerasimos Filippatos
- Heart Failure Unit, Department of Cardiology, Athens University Hospital Attikon, National and Kapodistrian University of Athens, Athens, Greece
| | - Jörg Hausleiter
- Department of Medicine I, University Hospital Munich, Ludwig-Maximilians University Munich, Germany
| | - Gerhard Hindricks
- Department of Electrophysiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | - Ewa A Jankowska
- Department of Heart Diseases, Wroclaw Medical University and Centre for Heart Diseases, University Hospital, Wroclaw, Poland
| | - Mitja Lainscak
- Division of Cardiology, General Hospital Murska Sobota, Murska Sobota, Slovenia.,Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Christoph Leclercq
- Université de Rennes I, CICIT 804, Rennes, CHU Pontchaillou, France, Rennes
| | - Lars H Lund
- Department of Medicine, Karolinska Institutet and Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden
| | | | - Mandeep R Mehra
- Brigham Women's Hospital Heart and Vascular Center and the Center of Advanced Heart Disease, Harvard Medical School, Boston, USA
| | - Marco Metra
- Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Italy
| | - Nathan Mewton
- Hôpital Cardio-Vasculaire Louis Pradel, Centre d'Investigation Clinique, Filière Insuffisance Cardiaqu, e, France, Lyon
| | - Christian Mueller
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Switzerland
| | - Wilfried Mullens
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium.,Faculty of Medicine and Life Sciences, Biomedical Research Institute, Hasselt University, Diepenbeek, Belgium
| | | | - Jean-Francois Obadia
- Department of Cardiac Surgery, "Louis Pradel" Cardiologic Hospital, Lyon, France
| | - Piotr Ponikowski
- Department of Heart Diseases, Wroclaw Medical University and Centre for Heart Diseases, University Hospital, Wroclaw, Poland
| | - Fabien Praz
- Department of Cardiology, Inselspital, University of Bern, Bern, Switzerland
| | - Volker Rudolph
- Clinic for General and Interventional Cardiology/Angiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | - Frank Ruschitzka
- Cardiology Clinic, University Heart Center, University Hospital Zürich, Switzerland
| | | | - Stephan Windecker
- Department of Cardiology, Inselspital, University of Bern, Bern, Switzerland
| | - Jose Luis Zamorano
- Cardiology Department, University Hospital Ramon y Cajal, Madrid, Spain.,University Alcala, Madrid, Spain.,CIBERCV, Instituto de Salud Carlos III, Madrid, Spain
| | - Thor Edvardsen
- Department of Cardiology, Centre of Cardiological Innovation, Oslo University Hospital, Rikshospitalet, Oslo, Norway.,Institute for Clinical Medicine, University of Oslo, Oslo, Norway
| | - Hein Heidbuchel
- Antwerp University and Antwerp University Hospital, Antwerp, Belgium
| | | | - Bernard Prendergast
- Department of Cardiology, St Thomas' Hospital, Westminster Bridge Road, London, UK
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21
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Coats AJ. Figures of the
H
eart
F
ailure
A
ssociation:
P
rof.
L
ars
H. L
und,
C
hair of the
HFA C
ommittee on
R
egistries,
S
urveys and
E
pidemiology and
HFA B
oard
M
ember (from 2016). Eur J Heart Fail 2020; 22:1941-1944. [DOI: 10.1002/ejhf.2014] [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: 08/23/2020] [Accepted: 08/27/2020] [Indexed: 11/08/2022] Open
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22
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Hicks A, Velazco JF, Gohar S, Seliem A, Hall SA, Michel JB. Advanced heart failure with reduced ejection fraction. Proc (Bayl Univ Med Cent) 2020; 33:350-356. [PMID: 32675952 DOI: 10.1080/08998280.2020.1765663] [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: 11/18/2019] [Revised: 02/10/2020] [Accepted: 02/20/2020] [Indexed: 10/24/2022] Open
Abstract
Patients suffering advanced heart failure with reduced ejection fraction (HFrEF) account for a large portion of patients admitted to hospitals worldwide. Mortality and 30-day readmission rates for HFrEF are now a focus of value-based payment models, making management of this disease a priority for hospitals, physicians, and payers alike. Angiotensin-converting enzyme inhibitors have been the cornerstone of therapy for decades. However, with treatment, the prognosis for patients with advanced HFrEF remains poor. Fortunately, advances in medical therapy and mechanical support offer some patients improvement in both survival and quality of life. We review advances in short- and long-term mechanical support and explore changes to organ allocation for cardiac transplantation. In addition, we provide a guide to facilitate appropriate referral to an advanced heart failure team.
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Affiliation(s)
- Albert Hicks
- Division of Cardiology, Baylor Scott and White Medical Center - TempleTempleTexas
| | - Jorge F Velazco
- Division of Pulmonary and Critical Care Medicine, Baylor Scott and White Medical Center - TempleTempleTexas
| | - Salman Gohar
- Division of Cardiology, Baylor Scott and White Medical Center - TempleTempleTexas
| | - Ahmed Seliem
- Baylor Scott & White Advanced Heart Failure Clinic, Baylor University Medical CenterDallasTexas
| | - Shelley A Hall
- Baylor Scott & White Advanced Heart Failure Clinic, Baylor University Medical CenterDallasTexas
| | - Jeffrey B Michel
- Division of Cardiology, Baylor Scott and White Medical Center - TempleTempleTexas
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23
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Guglin M, Zucker MJ, Borlaug BA, Breen E, Cleveland J, Johnson MR, Panjrath GS, Patel JK, Starling RC, Bozkurt B. Evaluation for Heart Transplantation and LVAD Implantation. J Am Coll Cardiol 2020; 75:1471-1487. [DOI: 10.1016/j.jacc.2020.01.034] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 01/02/2020] [Accepted: 01/07/2020] [Indexed: 12/11/2022]
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