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Plasma catecholamines may play an important role in Takotsubo cardiomyopathy (TCM) pathophysiology. Patients with disproportionately high catecholamine responses to stressful events are prone to worse clinical outcomes. Catecholamines stimulate platelet activation and, therefore, may determine the clinical presentation and outcomes of TCM. We conducted a retrospective, descriptive study TCM patients admitted between 2003 and 2013 to Einstein Medical Center, Philadelphia, PA, USA and Danbury Hospital, Danbury, CT, USA. A total of 206 patients met Modified Mayo TCM criteria. Using a multiple logistic model, we tested whether aspirin, dual antiplatelet therapy (DAPT) aspirin + clopidogrel, beta blocker, statin, or ACE inhibitor use were independent predictors of major adverse cardiovascular events (MACE) during the index hospitalization. MACE was defined as in-hospital heart failure, in-hospital death, stroke or respiratory failure requiring mechanical ventilation. Incidence of in-hospital heart failure was 26.7 %, in-hospital death was 7.3 %, stroke was 7.3 % and MACE was 42.3 %. In a multiple logistic regression model (adjusted for gender, race, age, physical stressor, hypertension, diabetes, hyperlipidemia, smoking history, body mass index, initial left ventricular ejection fraction, single antiplatelet therapy, DAPT, beta blocker, statin, and ACE inhibitor) aspirin and DAPT at the time of hospitalization were independent predictors of a lower incidence of MACE during the index hospitalization (aspirin: OR 0.4, 95 % CI (0.16-0.9), P = 0.04; DAPT: OR 0.23; 95 % CI (0.1-0.55); P < 0.01. Physical stressor itself was also found to be an independent predictor of worse MACE: OR 5.1; 95 % CI (2.4-11.5); P < 0.01. In our study, aspirin and DAPT were independent predictors of a lower incidence of MACE during hospitalization for TCM. Prospective clinical trials are needed to confirm the findings of this study. more...

Objectives: Chronic heart failure (CHF) has been associated with an increased risk of poorer cognitive performance in older adults. Reversibility of cognitive impairment after medical treatment has been reported, although the restorative effects of enhanced external counterpulsation (EECP) on cognitive performance have not been studied. We investigated the effect of EECP on cognitive functions in CHF patients., Study Design: Thirty-six individuals (mean age: 66±8 years) who were diagnosed with CHF and were New York Heart Association (NYHA) Class II-III and Canadian Cardiovascular Society (CCS) Class II-III participated in this study. Neuropsychological assessment was performed in these patients., Results: Patients in the EECP treatment group showed a statistically significant improvement in spontaneous naming (p=0.011) and forward row score of the attention subset among domains of cognition (p=0.020) and interference time of executive function (p=0.012)., Conclusion: Enhanced external counter pulsation resulted in improvement in all domains of cognitive functions except verbal and visual memory tests. more...

The goal of the study was to assess longitudinal changes in quality of life among patients who screened positive for depression and patients who did not enroll in an outpatient heart failure disease management program (HFDMP). Patients with an ejection fraction ≤40% and clinical signs and symptoms of heart failure were enrolled over 11 months from August 2007 to July 2008. Study participants (n=314) were divided at baseline into "depressed" (9-Question Patient Health Questionnaire [PHQ-9] ≥10) and "nondepressed" (PHQ-9 <10) groups. The two cohort groups had quality of life assessed by the Minnesota Living With Heart Failure Questionnaire at baseline and at 1 year while enrolled in the HFDMP. Both groups showed improved quality of life scores, with the depressed group experiencing a greater mean score decrease (14.4 vs 10.8 for nondepressed patients; P<.01). Both patients who screened positive for depression and those who did not enroll in an HFDMP improved their quality of life scores, with depressed patients experiencing a statistically significant greater mean score reduction (better quality of life)., (© 2011 Wiley Periodicals, Inc.) more...

Mean platelet volume (MPV) is increased in chronic heart failure (CHF) and is an independent predictor of mortality in CHF patients. It is not known whether enhanced external counterpulsation (EECP) therapy leads to decreased MPV values or not. The purpose of this study was to examine the effects of EECP on platelet count and MPV values and to assess the influence of MPV on the risk of death and recurrent ischemic events in ischemic CHF patients. A total of 68 ischemic heart failure patients with CHF symptoms and refractory angina pectoris were included in the study, 47 consecutive patients (39 males and eight females) aged 44-82 years. Although follow-up period started after completion of EECP in treated patients, control group follow-up started at the end of 7-week treatment without EECP. All patients were monitored for a mean duration of 13 ± 8 months (range, 1-36 months). The primary endpoints of the study were effects of EECP treatment on platelets after treatment period (7 weeks) and the recurrence of ischemic events. Secondary endpoint was cardiovascular death during the follow-up period. We observed a significant increase in platelet count and decrease in MPV levels (P = 0.044 and P = 0.004, respectively) in the control group. There were no significant differences in platelet count and MPV levels in the EECP group (P > 0.05). After the treatment period, New York Heart Association functional classification (2.60 ± 0.75 vs. 1.72 ± 0.68, P < 0.001) and Canadian Cardiovascular Society functional classification of angina (2.50 ± 0.90 vs. 1.60 ± 0.74, P < 0.001) improved in patients with EECP treatment. In our study, we found that EECP therapy had a neutral effect on MPV values and platelet count. more...

Caring for heart failure patients with a low socioeconomic status presents a unique set of challenges for health care providers. Heart failure disease management programs can integrate the use of teaching DVDs to overcome deficiencies in health literacy and take advantage of the Wal-Mart/Target $4 dollar medication program to provide life-saving medical therapy. In addition, open discussions with the patient and family regarding the costs of medications and the reality of what they can afford to pay monthly on a long term basis can guide the physician to prescribing medications by prioritizing use with a focus on evidence-based data for the medications with the highest mortality reduction. Finally, connecting inpatient visits to outpatient visits through the use of electronic medical records systems can facilitate avoidance of unnecessary repeat lab and diagnostic testing. more...

Background: Little is known about the importation of a heart failure disease management program (HFDMP) into low- and middle-income countries. We examined the feasibility of importing a HFDMP into the country of Georgia, located in the Caucuses., Methods and Results: Patients with ejection fraction ≤40% were enrolled into a prospective, observational study consisting of a new HFDMP staffed by local cardiologists. Medications, emergency department use, hospital admissions, and mortality were assessed by interviews with patients or their families. Screening resulted in 400 patients who were followed for 10.2±3.5 months. β-Blocker prescriptions increased from 7.4-80.7% (P<0.001), angiotensin-converting enzyme inhibitor prescriptions increased from 18.4-92.6% (P<0.001), and mean systolic blood pressure declined from 145 to 114 mm Hg (P<0.001). Patients visiting the emergency department and hospitalizations were lowered by 40.7% and 52.5%, respectively, but were also influenced by the outbreak of war, during which 17.5% (n=70) of patients received follow-up in refugee tents. All-cause mortality extended to 7% of patients, with 12 of 28 deaths caused by war-related events., Conclusions: Importation of a Western HFDMP was demonstrated to be feasible, with a 5-fold increase in the use of recommended therapies, reduction of blood pressure, decrease of emergency department visits, and hospitalizations for heart failure. These measures could result in substantial cost savings in resource-limited settings, but assessment is complicated in unstable areas. Translating effective interventions to low- and middle-income countries requires sensitivity to regional cultures and flexibility to adapt both clinical goals and strategies to unexpected conditions. more...

Objectives: This study assessed if patients enrolled in a heart failure disease management program (HFDMP) reach the JNC VII target goals for blood pressure (BP) control, eliminate disparities in hypertension control by race/ ethnicity and the impact BP control has on survival., Methods: Patients (N = 898) with an ejection fraction <40% were enrolled into two HFDMPs and screened for hypertension, defined as BP > 130/80., Results: Mean baseline systolic BP (SBP) 132 ± 25.5 mm Hg and diastolic BP (DBP) 79 ± 16.8 mm Hg. Final mean SBP decreased to 129.6 mm Hg, DBP 77.6 mm Hg. Whites had the highest rate of achieving BP goals. Mortality reduction was associated with minority race, history of hypertension, increase ejection fraction and statin use., Conclusion: HFDMPs are an effective way to reduce BP in hypertensive patients. Disparities by race and ethnicity were not seen after adjustment for disease modifiers. There was no mortality difference in those who reached BP goal. more...

The authors evaluated the prevalence of hypothyroidism in patients with heart failure (HF) to determine whether there are racial and sex differences and to determine the number of new cases of hypothyroidism. The study included 194 patients in an HF disease management program (HFDMP) in South Florida. Patients were interviewed for a history of hypothyroidism and referred for measurement of thyrotropin. The prevalence of hypothyroidism was calculated by race and sex. The prevalence of hypothyroidism was 18% for all patients with HF and 23% among Hispanics; however, this trend was not statistically significant (P = .06). More men than women had hypothyroidism (P = .04). Patients with hypothyroidism had higher mean lipid profiles (P < .01) and lower mean heart rates (P = .03) than healthy patients. Hypothyroidism is prevalent among HF patients, especially men. Hispanics with HF may have a higher prevalence of hypothyroidism. The standardized protocol of the HFDMP helped identify new cases of hypothyroidism., (© 2011 Wiley Periodicals, Inc.) more...

Background: The incidence of congestive heart failure (CHF) has not significantly declined over the past 50 years, and overall survival rates are low at 5 years following diagnosis. Numerous studies have shown low serum sodium to be a poor prognostic indicator of all cause mortality in CHF patients., Hypothesis: The goal of this hypothesis was to validate if hyponatremia is an important predictor of mortality in an outpatient population of CHF patients on maximal combined angiotensin-converting enzyme inhibitor (ACEI) and β-blocker therapy., Methods: A total of 364 (13% with hyponatremia) patients with CHF (ejection fraction [EF] ≤ 40%) were enrolled in a heart failure disease management program. The mean New York Heart Association (NYHA) class was II.XII. The average baseline serum sodium was 138.2 mEq/L., Results: We evaluated the relationship between hyponatremia (<135 mEq/L) and all-cause mortality at 40 months. During follow-up, 8 patients in the hyponatremia group compared to 31 in the normonatremic group died. Results of Kaplan-Meier analyses indicated there were no significant differences in mortality between the hyponatremia and normonatremic groups (log-rank test = 0.39). Results for Cox proportional hazards models indicated low sodium was not a significant predictor of mortality (unadjusted odds ratio [OR]: 1.41, 95% confidence interval [CI]: 0.65, 3.07; adjusted OR: 1.60, 95% CI: 0.57, 4.53)., Conclusions: The relationship between hyponatremia and all-cause mortality did not reach significance. Hyponatremia did not significantly predict mortality in a CHF population on maximal medical therapy. Copyright © 2010 Wiley Periodicals, Inc., (Copyright © 2010 Wiley Periodicals, Inc.) more...

Healthy People 2010 aims at immunizing 60% of high-risk adults annually against influenza and once against pneumococcal disease. The aim of this study was to evaluate the use of a standardized approach to improve vaccination rates in patients with heart failure (HF); to determine whether disparities exist based on age, race, ethnicity, or sex at baseline and follow-up; and to evaluate the impact of clinical variables on the odds of being vaccinated. A prospective study of 549 indigent patients enrolled in a systolic HF disease management program (HFDMP) began enrollment from August 2007 to January 2009 at Jackson Memorial Hospital. Patients were interviewed at their initial visit for immunization status; those without vaccinations were offered the vaccines. Prevalence of vaccination (POV) for influenza and pneumococcal disease was obtained at baseline and at follow-up. The odds ratio for being vaccinated was calculated using logistic regression. The study population comprised mostly Hispanic (56%), black (37%), and male (70%) patients, with a mean age of 56 ± 12 years and a mean ejection fraction of 25% ± 10%. The initial POV for both was 22% at baseline. At follow-up, POV improved to 60.5%. Of those not vaccinated at baseline, 17.5% refused vaccination. Odds ratios at baseline for age, race/ethnicity, and sex were 0.99 (P=.99), 0.63 (P=.08), and 0.62 (P=.14), respectively. These did not change significantly at follow-up. Prevalence of vaccination in our cohort was low. Enrollment into the HFDMP improved immunization prevalence without creating age, race, ethnicity, or sex disparities., (© 2010 Wiley Periodicals, Inc.) more...

Objective: To determine if B-natriuretic peptide (BNP), handheld ultrasound, and echo interpretation was an accurate and reliable screening for stage B heart failure., Methods: One hundred and forty-five indigent diabetic patients were prospectively enrolled, and their BNP levels were measured. Each patient underwent a handheld echo., Results: BNP was correlated with ejection fraction, but not with diastolic dysfunction. The area under the receiver-operator characteristic was 0.77. Kappa statistics for reliability in interpreting handheld echoes was 1.0., Conclusions: Results from this study suggested that BNP may be able to serve as a reliable screening tool for stage B heart failure in diabetic populations. Because BNP is an inexpensive blood test, it could be incorporated into the congestive heart failure diagnostic algorithm to determine which patients need imaging studies, namely echocardiography. Handheld echocardiography had interobserver reliability and is a promising alternative screening method. more...

More than 5 million people live with heart failure (HF) in the United States, and this number is expected to rise due to several factors including increased life expectancy brought about by medical therapy and the aging of the population. HF and peripheral arterial disease (PAD) share many risk factors. A review of the literature reveals several studies supporting a higher prevalence of HF in patients with PAD than in those without PAD. However, no study was found that estimates the prevalence of PAD in patients with HF. Moreover, the prevalence of PAD by US race/ethnic groups with HF has not been studied. The authors conducted a cross-sectional multicenter study of patients enrolled in an HF disease management program in Louisiana (n=330) and Florida (n=464). All patients with an ejection fraction more...

Background: Data on racial and gender differences in mortality in patients followed in a standardized heart failure disease management program (HFDMP) are scarce., Methods: Survival was calculated by race/ethnicity and gender for 837 patients enrolled in a HFDMP. (The patients studied were indigent African American and White outpatients [39% African American, 36% female] enrolled into at Leonard J. Chabert Medical Center in Houma, Louisiana.) The hazard ratio associated with demographic and clinical characteristic individually and as a whole, was estimated for the four groups., Results: White males had the highest mortality (African American female: HR=0.64, African American male: HR=0.65, White female: HR=0.67, p<.05). Age (HR=1.04, p<.001), ejection fraction (HR=0.97, p<.001), New York Heart Association (NYHA) (HR=1.57, p<.001), systolic blood pressure (HR=0.99, p<.05), hematocrit (HR=0.96, p<.01), diabetes (HR=0.98, p<.05), and body mass index (HR=0.98, p<.05) were significant predictors of mortality in the univariate model. Age (HR=1.04, p<.001), NYHA (HR=1.40, p<.001), diabetes (HR=2.52, p<.001), and White female (HR=.44, p<.01) were significant predictors of mortality in the multivariate model., Conclusion: With the exception of White females, who demonstrated lower mortality, amongst African American males and females and White males who participated in a HFDMP no difference in survival was observed. more...

The prevalence of electrocardiographic (ECG) abnormalities in systolic heart failure patients have predominantly been described in white patients, with relatively little known about their prevalence in black and Hispanic populations. The purpose of this study is to compare the prevalence of ECG abnormalities by race, ethnicity, and sex. The authors conducted an observational prospective study that included 926 patients from 2 hospital facilities. A systolic heart failure disease management program implemented in both sites enrolled patients with an ejection fraction < or =40% by echocardiography. Black patients had less evidence of myocardial infarction than whites and Hispanics. Black patients had more evidence of left ventricular hypertrophy than Hispanics and whites. Hispanics evidenced more ischemic changes than blacks and whites. Among black patients, left ventricular hypertrophy was more prevalent in women. ECG abnormalities vary across race, ethnicity, and sex. These variations may have implications for further diagnostic testing and potential treatment regimens., (2009 Wiley Periodicals, Inc.) more...

Introduction: Seventy percent to 90% of patients with heart failure (HF) report erectile problems. There are no published data on whether erectile dysfunction (ED) and peripheral vascular disease (PVD) correlate with mortality in HF patients. Also, little is known regarding the impact of HF etiology on mortality in patients with ED., Aims: Our aim was to investigate the relationship between ED and mortality in HF patients, to evaluate whether the etiology of HF carries a prognostic measure in patients with ED, and to assess the impact of PVD on mortality in optimally treated HF patients with ED., Main Outcome Measures: The measures are: (i) mortality by presence or absence of ED; (ii) mortality by HF etiology and presence or absence of ED; and (iii) PVD and mortality in HF patients on optimal medical therapy with ED., Methods: This is a single-center, prospective cohort study of 328 male HF patients (ejection fraction < or = 40%) followed while being treated with optimal doses of beta blockers and angiotensin-converting enzyme inhibitors. The Sexual Health Inventory for Men survey was used to assess ED (no ED > or = 22 and ED < or = 21). Ankle brachial index (ABI) was used to assess PVD (normal ABI > or = 0.9 and abnormal ABI < 0.9)., Results: Kaplan-Meier curves were constructed to examine the relationship between the presence or absence of ED and PVD, and mortality in a HF population. Although not statistically significant, a trend for increased risk of death was demonstrated in the ischemic cardiomyopathy cohort with ED., Conclusions: ED, highly prevalent in this cohort, did not identify HF patients on optimal medical therapy at increased risk for mortality. Among the HF patients with ED, HF type was not associated with increased risk for mortality whereas PVD was independently associated with a statistically significant increase in mortality. more...

Background: Metabolic syndrome (MetS) is a risk factor for diabetes, cardiovascular disease, and heart failure, but little is known about the impact of MetS in patients who already have heart failure (HF)., Hypothesis: MetS increases mortality in HF., Methods: We performed an analysis in 865 indigent HF patients enrolled in a HF disease management program at the Chabert Medical Center in Louisiana. All subjects were classified as having MetS if they met three or more of the National Cholesterol Education Program criteria. Mortality was defined using the Social Security Death Index. We calculated the relative hazard (RH) of death for those patients with and without MetS., Results: The prevalence of MetS was 40% (95% confidence interval [CI]: 37-43). These subjects had similar ages (54.3+/-13.4 vs 55.7+/-12.8 years), more likely to be female (43% vs 33%), had similar baseline ejection fraction (31.4+/-9.7 vs 30.0+/-11.0), and New York Heart Association (NYHA) classification (2.20+/-0.9 vs 2.15+/-0.9). After 2.6+/-2.2 years of follow-up 24% of the MetS group died compared to 16% in the non-MetS group (p < 0.01). The RH of death for the MetS group was 1.5 (95% CI: 1.1-2.1) when compared to the non-MetS group after adjustment demographics, use of angiotensin-converting enzyme (ACE) inhibitor and beta-blocker, hematocrit, creatinine, educational level, and baseline ejection fraction., Conclusions: The prevalence of MetS is high in indigent HF patients, and it increases the risk of death. Physicians treating patients with HF need to address the current MetS epidemic in HF., (2009 Wiley Periodicals, Inc.) more...

Background: Research regarding the use of implantable devices in patients with congestive heart failure (CHF) has shown mortality benefits. The Center for Medicare and Medicaid Services (CMS) approved new criteria for expanding coverage for such therapies. The purpose of this study was to determine the percentages of CHF patients in a rural, indigent heart failure population that would be eligible for implantable defibrillators (ICD) and cardiac resynchronization therapy (CRT) based on the new CMS criteria., Methods and Results: The new CMS guidelines were applied to information compiled in a database for 451 CHF disease management patients, at Leonard J. Chabert Medical Center. Results show that, annually, 32% of the newly identified CHF patient population would be eligible for ICD therapy and 7.3% would be eligible for CRT therapy., Conclusions: Providers of health care to the indigent may lack sufficient resources for the devices and the infrastructure for device implantation and follow-up. more...

beta-Blocker therapy has changed the landscape of treatment for chronic heart failure (HF). First recommended in published guidelines in 1999, the use of beta-blockers has become the cornerstone of therapy. beta-Blockers reduce both morbidity and mortality and also improve quality of life. This paper reviews and highlights the evidence supporting the current usage of beta-blockers in HF. It also shares practical, real world tricks-of-the-trade regarding such usage drawn from 8 years of experience with over 3000 patients in eight safety net hospitals. Each hospital mentioned in this paper participates in an HF disease management program serving the needs of Louisiana's indigent population. more...

Anemia has been described as an independent predictor of death in patients with chronic heart failure. Little is known, however, about the significance of anemia in heart failure patients with severely depressed socioeconomic backgrounds who receive comprehensive care in a heart failure management program. The impact of anemia on mortality was investigated in 410 indigent chronic heart failure patients, the majority of whom were in New York Heart Association functional class I-III and were treated with angiotensin-converting enzyme inhibitors or angiotensin receptor blockers and beta blockers at maximally tolerated doses. Anemia was present in 28% of patients. In an adjusted Cox analysis, anemia was strongly associated with mortality, but only in men: hazard ratio, 2.54; 95% confidence interval, 1.31-4.93; p = 0.006. The investigators conclude that anemia in this population is common and that, for men, the relative risk increase associated with anemia is high. more...