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Aims: The objective of this study was to examine associations between elevated depressive symptoms and increased risk of adverse clinical events patients with heart failure and reduced ejection fraction (HFrEF), as well as the potential contribution of health behaviours. Methods and results: One hundred forty‐two men and women with HFrEF were enrolled through heart failure (HF) clinics and followed over time. At baseline and 6 months, depressive symptoms were assessed by the Beck Depression Inventory‐II (BDI‐II) and HFrEF disease activity by B‐type natriuretic peptide (BNP). The Self‐Care of Heart Failure Index (SCHFI) was used to assess HF self‐care behaviours. Proportional hazards regression models assessed the contribution of depressive symptoms and HFrEF disease biomarkers on death or cardiovascular hospitalization. Over a median follow‐up period of 4 years, 42 patients (30%) died, and 84 (60%) had cardiovascular hospitalizations. A 10‐point higher baseline BDI‐II score was associated with a 35% greater risk of death or cardiovascular hospitalization. Higher baseline BDI‐II scores were associated with poorer HF self‐care maintenance behaviours (R = −0.30, P < 0.001) and fewer daily steps (R = −0.19, P = 0.04), suggesting that elevated depressive symptoms may diminish important health behaviours. Increases in plasma BNP over 6 months were associated with worse outcomes. Changes in BDI‐II and plasma BNP over 6 months were positively related (R = 0.25, P = 0.004). Conclusions: This study confirms that elevated depressive symptoms are associated with an increased likelihood of adverse clinical outcomes in patients with HFrEF. Poor health behaviours may contribute to the adverse association of elevated depressive symptoms with the increased hazard of adverse clinical outcomes. [ABSTRACT FROM AUTHOR]

• Clinical presentation of acute Chagas disease reactivation after heart transplant • Histologic features of acute Chagas disease reactivation in endomyocardial biopsy • Epidemiologic risk-factors for Chagas disease in non-endemic countries Acute Chagas disease reactivation (CDR) after cardiac transplantation is a well-known phenomenon in endemic countries of Central and South America and Mexico, but is rare outside of those countries. In this report, we describe a case of a 49-year-old male who presented 25 weeks after heart transplant with clinical features concerning for acute rejection, including malaise, anorexia, weight loss, and fever. His immunosuppression therapy included tacrolimus, mycophenolate, and prednisone. An endomyocardial biopsy revealed lymphocytic and eosinophilic inflammation, myocyte damage, and rare foci of intracellular organisms consistent with Trypanosoma cruzi amastigotes. The patient had no known history of Chagas disease. Upon additional questioning, the patient endorsed bites from reduviid bugs during childhood in El Salvador. Follow-up serum PCR testing was positive for T. cruzi DNA. Tests for other infectious organisms and donor specific antibodies were negative. This case illustrates the striking clinical and histologic similarities between acute cellular rejection and acute CDR with cardiac involvement in heart transplant patients, and thus emphasizes the importance of pre-transplant testing for Chagas in patients with epidemiologic risk factors. [ABSTRACT FROM AUTHOR]

End-stage heart failure (HF) is associated with an extremely poor prognosis. Progressive and/or persistent HF signs and symptoms in the setting of optimal therapy is the hallmark of more advanced disease. Physicians must be able to recognize patients with features of refractory HF to aid in timely evaluation for advanced therapy options. Left ventricular assist device implantation and heart transplantation prolong survival in patients with end-stage HF, but are options only for select patients. Timely referral for evaluation is necessary to prevent secondary irreversible end-organ dysfunction and to ascertain whether there are factors that can be addressed and corrected. All patients with end-stage HF should be offered referral for palliative care to aid in symptom management and improve quality of life. In addition, for patients who are not candidates for advanced therapy options, hospice should be discussed. In some cases, palliative home inotrope infusion can be considered for symptom management.

Echocardiography is valuable in the evaluation and risk stratification of patients with acute and chronic pulmonary embolism (PE). Patients with acute PE who have echocardiographic evidence of right ventricular dilatation and/or right ventricular dysfunction have a worse prognosis. A minority of patients with acute PE can develop chronic thromboembolic pulmonary hypertension. Patients with chronic thromboembolic pulmonary hypertension often have echocardiographic evidence of elevated pulmonary arterial pressures, right ventricular hypertrophy, right ventricular dysfunction, and/or left ventricular impaired relaxation., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Pulmonary arterial hypertension (PAH) is a panvasculopathy that affects the distal pulmonary arteries and leads to restricted blood flow. This increased afterload leads to adaptive mechanisms of the right ventricle, with eventual failure once it can no longer compensate. Pulmonary hypertension from associated conditions, most importantly left heart disease, i.e. heart failure, can also lead to the same sequela. Patients often experience early vague symptoms of dyspnea and exercise intolerance, and thus PH can elude clinicians until right heart failure symptoms predominate. Evidence-based treatment options with pulmonary vasodilators are available for those with PAH and should be employed early. It is essential that patients be accurately categorized by their etiology of PH, as treatment strategies differ, and can potentially be dangerous if employed in the wrong clinical scenario.