Search

Acute pulmonary embolism (PE) continues to be a leading cause of hospital admission with significant associated short and long term adverse events, including mortality. The PESI (Pulmonary Embolism Severity Index) score is a well known prognostic model derived to risk stratifies patients presenting

Acute pulmonary embolism (PE) continues to be a leading cause of hospital admission with significant associated short and long term adverse events. The PESI (Pulmonary Embolism Severity Index) score is a well known prognostic model derived to risk stratifies patients presenting with acute PE.

Heart failure with preserved ejection fraction (HFpEF) is a major cause of HF-related morbidity and mortality, with no medical therapy proven to modify the underlying disease process and result in improvements in survival. With long-standing pulmonary venous congestion, a majority of HFpEF patients develop pulmonary hypertension (PH). Elevated pulmonary pressures have been shown to be a major determinant of mortality in this population. Given the paucity of available disease-modifying therapies for HFpEF, there has been a considerable interest in evaluating new therapeutic options specifically targeting PH in this patient population.

The endothelin pathway is a key pathway for the pathogenesis of pulmonary arterial hypertension (PAH). Antagonism of this pathway is recommended as initial therapy in low-risk patient with PAH to inhibit fibrosis, cell proliferation, and inflammation caused by endothelin. Prior to October 2013, ambrisentan, a selective ETA receptor antagonist and bosentan, a dual ETA/ETB antagonist, were the only currently available agents for PAH targeting the endothelin pathway. Based on the results of the SERAPHIN trial, macitentan (brand name Opsumit®), a new ETA/ETB antagonist, has been US FDA approved to delay disease progression and reduce hospitalizations for PAH. SERAPHIN is the first ERA trial to use an event-driven strategy with a composite primary end point of morbidity or mortality. Previous trials have focused on short-term outcomes, such as improved 6-min walk distance and WHO functional class.

Purpose Cytomegalovirus (CMV) infection has been implicated in the pathogenesis of allograft rejection, which is reflected by high gene-expression profiling (GEP) scores. The effect of CMV infection on serial GEP scores in the absence of acute cellular rejection (ACR) is unknown. Methods Data from 14,985 samples collected from 2288 heart transplant (HT) recipients enrolled in Outcomes AlloMap® Registry (OAR) were analyzed. The empirical distribution of GEP scores at the visit closest to CMV infection were compared to GEP scores obtained at other visits via Kolmogorov-Smirnov tests. AlloSure measurements from those who underwent concurrent dd-cfDNA testing were also reviewed. Results 311 samples were collected from 213 patients with CMV infection at the time of GEP testing. The mean time to CMV infection from transplant was 346 days. Median GEP score at the time of diagnosis of CMV infection was significantly higher when compared to GEP score obtained at other visits (34 v 30, p Conclusion CMV infections in HT recipients are associated with an increase in GEP score independent of associated ACR. The likely mechanism is immune activation/modulation of one or more of the 11 genes in the GEP signature. Hence, CMV status should be considered when clinically interpreting high GEP scores. AlloSure testing in conjunction with AlloMap demonstrates AlloSure is invariant to CMV infection.

Background Cardiac allograft vasculopathy (CAV) remains an important cause of graft failure after heart transplantation (HT). Although many risk factors for CAV have been identified, there are no clinical prediction models that enable clinicians to determine each recipient's risk of CAV. Methods We studied a cohort of 14 328 heart transplant recipients whose data were reported to the International Society for Heart and Lung Transplantation Registry between 2000 and 2010. The cohort was divided into training (75%) and test (25%) sets. Multivariable modeling was performed in the test set using variables available at the time of heart transplant using three methods: (i) stepwise Cox proportional hazard, (ii) regularized Cox proportional hazard, and (iii) Bayesian network. Results Cardiac allograft vasculopathy developed in 4259 recipients (29.7%) at a median time of 3.0 years after HT. The regularized Cox proportional hazard model yielded the optimal performance and was also the most parsimonious. We deployed this model as an Internet-based risk calculator application. Conclusions We have developed a clinical prediction model for assessing a recipient's risk of CAV using variables available at the time of HT. Application of this model may allow clinicians to determine which recipients will benefit from interventions to reduce the risk of development and progression of CAV.

Chronic thromboembolic pulmonary hypertension (CTEPH) is a potentially life-threatening condition characterized by obstruction of pulmonary arterial vasculature by acute or recurrent thromboemboli with subsequent organization, leading to progressive pulmonary hypertension and right heart failure. Until relatively recently, CTEPH was a diagnosis made primarily at autopsy, but advances made in diagnostic modalities and surgical pulmonary endarterectomy techniques have made this disease treatable and even potentially curable. Although published guidelines are available, in the absence of randomized controlled trials regarding CTEPH there is a lack of standardization, and treatment options have to be individualized.

Background: Adherence to heart failure core measures has been a focus of all hospitals in the past several years and has become even more important with the advent of pay for performance. Core measures address basic heart failure care, but do not include utilization of all evidence-based therapies which improve long term outcomes. We hypothesized that an in-hospital multidisciplinary heart failure (HF) management program could improve adherence to evidence-based guidelines beyond core measures. Methods: As a quality improvement initiative, we formed a multidisciplinary team to improve compliance with HF evidence-based therapy. Interventions included multiple educational sessions, discharge and post-discharge transition improvements, concurrent and post-discharge chart abstraction, revised patient education, and real-time provider education. Charts were abstracted in 525 consecutive HF inpatients between Jul 2010 and Mar 2011. Data was collected in the GWTG-HF (Outcome Inc) Registry. Pre-intervention compliance data (Jul-Sep) was compared to post-intervention (Nov-Mar) data with a paired t test and the Mann-Whitney rank sum test. Direct variable cost was analyzed for defect-free cases versus cases with defects. Results: Baseline Demographics: Mean age was 69 years, 42% female, 20% black, 55% ischemic etiology, mean LVEF=37%. Prior to the multidisciplinary intervention, overall defect-free care was excellent at over 89% (see figure) but there was a relative underutilization of aldosterone antagonists, hydralazine/nitrate therapy, CRT-D and anticoagulation for AF. Post-intervention, adherence improved to over 90% for all 8 evidence based therapies including: evidence-based beta-blocker (p=0.002), aldosterone antagonist (p Conclusions: In this single center experience, interventions led by a HF multidisciplinary team can significantly improve adherence to evidence-based therapies, beyond core HF measures. A multidisciplinary approach to inpatient HF care has the potential to decrease HF related costs.

As opposed to iatrogenic coronary dissection, spontaneous dissection is an extremely rare clinical condition. Typically seen in a single coronary vessel of peripartum women presenting with acute coronary syndrome, there are isolated case reports of men presenting multivessel involvement for this life-threatening condition. We describe a 54-year-old male with a history of diabetes, hypertension and methamphetamine abuse who presented to the emergency after a brief, witnessed cardiac arrest. Admission ECG revealed sinus tachycardia with inferior Q waves. He was found to have frequent runs of non-sustained ventricular tachycardia and minimal troponin-T elevation. His 2-D echocardiogram showed apical akinesis with an ejection fraction of 50%. Cardiac catheterization revealed a patent left main artery with a spontaneous dissection involving the mid to distal LAD artery, as well as large first diagonal branch with proximal dissection. His dominant RCA also showed long spontaneous dissection extending from proximal to distal vessel, along with distal focal 90% atherosclerotic lesion. Ramus intermedius and left circumflex vessels were free of disease. The patient underwent a 2-vessel coronary artery bypass grafting (CABG) with excellent outcome. Although cocaine abuse has been known to be associated with spontaneous dissection, this is the first reported case of a methamphetamine user presenting with multivessel coronary dissection.

Malignant thymoma is rarely associated with giant cell myocarditis. We present a case study that illustrates this association and cardiogenic shock with underlying tamponade. The dramatic presentation of this scenario has not been previously described.

Incidence of sudden cardiac death (SCD) in end-stage renal disease (ESRD) remains high. Limited data is available about whether implantable cardioverter-defibrillators (ICDs) can prevent arrhythmic death in patients with chronic kidney disease (CKD). The purpose of this retrospective study was to determine the impact of CKD on all-cause and sudden cardiac death in ICD recipients. We evaluated 441 consecutive patients who underwent ICD implantation at our center between 1994 and 2002. We found that mortality rate was higher in patients with eGFR<60 mL/min and those with ESRD on hemodialysis (43%,n=69/162and 54%,n=12/22, resp.) than in patients with eGFR≥60 mL/min (23%,n=58/257;P<.0005). The SCD rate was also higher in the patients with ESRD (50%) than in CKD patients not on dialysis (10.2%;P<.0005). Mortality rate for single-chamber ICDs was 56.8% in comparison with dual-chamber ICDs (38.1%) and for biventricular ICDs (5.0%) (P<.0005).

We present a 17‐y‐old male who presented to the emergency room with left arm weakness along with slurred speech. On physical examination, he had stable vital signs with left facial weakness suggestive of lower motor neuron seventh nerve palsy. He was also noted to have a small pulsatile mass in the right infraclavicular region. Further questioning revealed that 3 mo earlier he had suffered blunt chest wall trauma during a football game with fracture–dislocation of the right clavicular head, which was managed conservatively. MRI of the brain showed right frontal cortical changes suggestive of infarct versus vasculitis or edema. Chest CT revealed a 2.5‐ to 3‐cm pseudoaneurysm arising from the brachiocephalic artery, with thrombus formation, along with a surrounding 3 × 4.5 cm hematoma. The patient underwent a successful repair of the pseudoaneurysm with no further neurological sequelae. Traumatic pseudoaneurysm with thrombus formation is an extremely rare cause of stroke. It has been reported in association with the carotid artery, but to our knowledge, this is the first reported case with isolated innominate artery pseudoaneurysm. This case highlights the need for a broad differential when evaluating young patients with neurological deficits. Copyright © 2009 Wiley Periodicals, Inc.

Primary tumors of the heart are rare, with an incidence between 0.0017 and 0.19 percent in unselected patients at autopsy. About three-quarters of these tumors are benign, and nearly half of these benign tumors are myxomas. First described in 1845, myxomas were diagnosed posthumously until the 1950s. The clinical features are determined by their size, locations and mobility. Embolism occurs in one-third of patients, but it is rare for patients to initially present with multiple, simultaneous widespread emboli.

The 2003 Infectious Diseases Society of America guidelines for community-acquired pneumonia (CAP) recommend the initiation of antibiotic therapy within 4 h of hospitalization. This quality indicator has been linked to the incentive compensation of third-party payers to hospitals. We evaluated the impact of this recommendation on the diagnosis of CAP and the utilization of antibiotics.All patients with a hospital admission diagnosis of CAP before publication of the guidelines (January to June 2003) and after publication of the guidelines (January-June 2005) were included. We collected data on clinical signs and symptoms on presentation, chest radiograph findings, blood cultures prior to therapy with antibiotics, time to antibiotic administration, pneumonia severity index (PSI) score, confusion, urea, respiratory rate, BP, and ageor= 65 years (CURB-65), and mortality.A total of 518 patients were included in the study. More patients in 2005 had a hospital admission diagnosis of CAP without radiographic abnormalities compared to 2003 (2005, 91 patients [28.5%]; 2003, 41 patients [20.6%]; p = 0.04), and more patients received antibiotics within 4 h of triage (2005, 210 patients [65.8%]; 2003, 107 patients [53.8%]; p = 0.007). Blood cultures prior to antibiotic administration increased (2005, 220 patients [69.6%]; 2003, 93 patients [46.7%]; p0.001). However, the final diagnosis of CAP dropped to 58.9% in 2005 from 75.9% in 2003 (p0.001). The mean (+/- SD) antibiotic utilization per patient increased to 1.66 +/- 0.54 in 2005 compared to 1.39 +/- 0.58 in 2003 (p0.001). There were no significant differences in PSI or CURB-65 scores, or mortality.Linking antibiotic administration within 4 h of hospital admission (as a quality indicator) to financial compensation may result in an inaccurate diagnosis of CAP, inappropriate utilization of antibiotics, and thus less than optimal care.

Purpose Inotropic therapy is currently viewed as deleterious and a last option for Stage D heart failure (HF). Previous studies evaluated patients on intravenous inotropic therapy prior to the AICD era with a high 6-month mortality. We evaluated duration of therapy and mortality in patients with an AICD on chronic inotropic therapy. Methods and Materials We performed a single-center retrospective analysis of patients with NYHA class IV stage D HF who were discharged from the hospital on chronic inotropic therapy from June 2007 until November 2012. Inotropes that were analyzed included both Milrinone and Dobutamine. Patients without an AICD were excluded. Results There were 104 patients (53 palliative, 27 cardiac transplant and 24 left ventricular assist device (LVAD)) included; 82% were male and the average age at inotrope initiation was 64 years. The majority of patients (90%) were started on Milrinone. The mean duration of inotropic therapy was 169 days (range 2 - 1179 days). In each subgroup, the average duration of support was palliative 224 days (range 3 – 1179 days), cardiac transplant 135 days (range 2 – 838 days) and LVAD 74 days (range 14 – 741 days). In the palliative group, there were 30 deaths and 10 were weaned from inotropes. Kaplan Meier curve reveals an initial early mortality and then stabilizes thereafter Figure 1 . The mean survival time was 407 days (SEM 72d) on palliative inotropes; 70% (37/53) of patients survived >60 days and their average duration of support increased to 305 days. No deaths were noted in patients awaiting LVAD or transplant. There were no sudden deaths. Conclusions In patients with Stage D HF, chronic inotropic therapy may be viable option as palliation, bridge to LVAD and cardiac transplantation.

Purpose: DTRS was developed to predict risk of 90 day in hospital mortality in DT pts with pulsatile flow LVADs from 2002-2005. Discrimination of mortality using DTRS in BTT and DT pts with continuous flow LVADs is dubious, with reported c-statistics of 0.54-0.59. We sought to reinvestigate its applicability in continuous flow LVADs at our center. Methods and Materials: Charts for 88 pts with continuous flow LVADs implanted from 2007-2011 were reviewed. DTRS was calculated for 76 pts and divided into low, medium, high and very high risk categories. Outcomes were measured at discharge, 1, 3 and 12 months. Z score was used to assess difference between the DTRS predicted and actuarial survival rate. Results: Mean age was 59 yrs with 77% men, 58% ischemic myopathy, and mean LVEF of 16% in 23 DT, 58 BTT and 7 BTD LVADs. Overall 30-day survival was 92% with 14 deaths occurring prior to hospital discharge. One-year survival, censored for transplant(n 34) or explant(n 2) was 55%. A medium DTRS overestimated mortality at hospital discharge, whereas a very high score overestimated mortality at both discharge and 90 days. Univariate predictors of 90-day mortality included need for dialysis (p 0.002), no ACEI/ARBs on admission (p 0.04) and DTRS (p 0.04). By multivariate analysis, DTRS was an independent predictor of 90-day mortality(p 0.01), though interpretation is limited by low event rate (n 14).

Prognostic Importance of Serial Evaluation of Blood Urea Nitrogen in Ambulatory Patients with Chronic Systolic Heart Failure and Preserved Renal Function Clay A. Cauthen, Matthew Tong, Yuping Wu, Anil Jain, W.H. Wilson Tang; Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, OH; Department of Internal Medicine, Kettering Medical Center, Kettering, OH; Department of Mathematics, Cleveland State University, Cleveland, OH; Division of Information Technology, Cleveland Clinic Foundation, Cleveland, OH

A young teenager with no known medical history presented to the emergency department (ED) with abrupt onset of palpitations and dizziness. She later had a generalised tonic colonic seizure, and a bout of vomiting containing pills. She admitted to have had an overdose of bupropion pills. A pill count was performed and her total dose ingestion was calculated to be 3.6 g. A 12-lead ECG showed sinus tachycardia and diffuse ST segment elevation in leads V1–V6, I and aVL, with ST …

What is the topic of this review? Patients with advanced heart failure who are implanted with left ventricular assist devices (LVADs) present an opportunity to understand the human circulation under extreme conditions. What advances does it highlight? LVAD patients have a unique circulation that is characterized by a reduced or even absent arterial pulse. The remarkable survival of these patients is accompanied by circulatory complications, including stroke, gastrointestinal bleeding and right-heart failure. Understanding the mechanisms related to the complications in LVAD patients will help the patients and also advance our fundamental understanding of the human circulation in general.Some humans with chronic, advanced heart failure are surgically implanted with a left ventricular assist device (LVAD). Because the LVAD produces a continuous flow, a palpable pulse is often absent in these patients. This allows for a unique investigation of the human circulation and has created a controversy around the 'need' for a pulse. The medical debate has also generated a more generic, fundamental discussion into what is 'normal' arterial physiology and health. The comprehensive study and understanding of the arterial responses to drastically altered haemodynamics due to continuous-flow LVADs, at rest and during activity, presents an opportunity to significantly increase our current understanding of the fundamental components of arterial regulation (flow, blood pressure, sympathetic activity, endothelial function, pulsatility) in a way that could never have been studied previously. In a series of four articles, we summarize the talks presented at the symposium entitled 'Bionic women and men - Physiology lessons from implantable cardiac devices' presented at the 2019 Annual Meeting of The Physiological Society in Aberdeen, UK. The articles highlight the novel questions generated by physiological phenomena observed in LVAD patients and propose future areas of interest within the field of cardiovascular physiology.

What is the topic of this review? Right heart dysfunction remains a major adverse event in patients with end stage heart failure undergoing left ventricular assist device placement. This article reviews the pathophysiology and clinical considerations of right heart failure in this patient population. What advances does it highlight? This review highlights the anatomic and physiological peculiarities of the interplay between left and right heart function in patients undergoing LVAD therapy. These would allow us to further advance our understanding of right ventricular function.The adaptation of the right ventricular (RV) output to a left ventricular assist device (LVAD) often determines the fate of patients with pulmonary hypertension secondary to left heart failure. Pre-existing right heart dysfunction in patients with advanced left heart failure is the consequence of increased (arterial) afterload and not simply the consequence of myocardial disease. If unaccounted for, it has the potential of accelerating into clinical right heart failure after LVAD, leading to significant morbidity and mortality. After LVAD implantation, the RV has to face increased flow generated by the LVAD, cardiac arrhythmias and exaggerated functional interactions between both ventricles. Understanding the key physiological mechanisms of RV dysfunction in patients with end-stage heart failure will allow us to predict and therefore prevent RV failure after LVAD implantation.

Supplemental material, CORA_Interview_questions_online_supp for Factors Affecting Health Care Engagement of Patients With End-Stage Heart Failure: An Exploratory Survey Study by Lisa Carey Lohmueller, Aakanksha Naik, Luke Breitfeller, Colleen K. McIlvennan, Manreet Kanwar, Srinivas Murali, Carolyn Rosé and James F. Antaki in MDM Policy & Practice

Supplemental material, CORA_Interview_questions_online_supp for Factors Affecting Health Care Engagement of Patients With End-Stage Heart Failure: An Exploratory Survey Study by Lisa Carey Lohmueller, Aakanksha Naik, Luke Breitfeller, Colleen K. McIlvennan, Manreet Kanwar, Srinivas Murali, Carolyn Rosé and James F. Antaki in MDM Policy & Practice