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Roehm B, McAdams M, Gordon J, Zhang S, Xu P, Grodin JL, Hedayati SS. Association of suPAR, ST2, and galectin-3 with eGFR decline and mortality in patients with advanced heart failure with reduced ejection fraction. J Investig Med 2024:10815589241249991. [PMID: 38715217 DOI: 10.1177/10815589241249991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/24/2024]
Abstract
Patients with heart failure with reduced ejection fraction (HFrEF) are at risk for chronic kidney disease (CKD). Elevated levels of circulating biomarkers soluble urokinase plasminogen activator receptor (suPAR), galectin-3, soluble suppression of tumorigenicity 2 (ST2), and N-terminal prohormone B-type natriuretic peptide (NT-proBNP) are associated with CKD progression and mortality. The predictive value of these biomarkers in a population with HFrEF and kidney disease is relatively unknown. We sought to determine whether these biomarkers were associated with longitudinal trajectory of estimated glomerular filtration rate (eGFR) in HFrEF and assess their association with mortality using a joint model to account for competing risks of ventricular assist device (VAD) implantation and heart transplantation. We included participants from the Registry Evaluation of Vital Information for Ventricular Assist Devices in Ambulatory Life with repeated eGFR measures over 2 years. Of 309 participants, mean age was 59 years, median eGFR 60 ml/min/1.73 m2, 45 participants died, 33 received VAD, and 25 received orthotopic heart transplantation. Higher baseline serum standardized suPAR (β coefficient = -0.36 √(ml/min/1.73 m2), 95% confidence interval (-0.48 to -0.24), p < 0.001), standardized galectin-3 (-0.14 √(ml/min/1.73 m2) (-0.27 to -0.02), p = 0.02), and log NT-proBNP (-0.23 √(ml/min/1.73 m2) (-0.31 to -0.15), p < 0.001) were associated with eGFR decline. ST2 and log NT-proBNP were associated with mortality. Higher baseline suPAR, galectin-3, and NT-proBNP are associated with eGFR decline in patients with HFrEF. Only ST2 and NT-proBNP are associated with greater mortality after controlling for other factors including change in eGFR. These biomarkers may provide prognostic value for kidney disease progression in HFrEF and inform candidacy for advanced heart failure therapies.
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Affiliation(s)
- Bethany Roehm
- Division of Nephrology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Meredith McAdams
- Division of Nephrology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Jonathan Gordon
- Division of Cardiology, Rush University Medical Center, Chicago, IL, USA
| | - Song Zhang
- Peter O'Donnell Jr. School of Public Health, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Pin Xu
- Division of Nephrology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Justin L Grodin
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - S Susan Hedayati
- Division of Nephrology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
- Division of Nephrology and Hypertension, Renaissance School of Medicine, Stony Brook University, Stony Brook, NY, USA
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Roehm B, McAdams M, Gordon J, Grodin JL, Hedayati SS. Association of Ratio of eGFR by Cystatin C and Creatinine with Mortality in Heart Failure. KIDNEY360 2024; 5:02200512-990000000-00332. [PMID: 38345438 DOI: 10.34067/kid.0000000000000384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 01/29/2024] [Indexed: 02/21/2024]
Affiliation(s)
- Bethany Roehm
- University of Texas Southwestern Medical Center, Dallas, TX, Division of Nephrology
| | - Meredith McAdams
- University of Texas Southwestern Medical Center, Dallas, TX, Division of Nephrology
| | - Jonathan Gordon
- Rush University Medical Center, Chicago, IL, Division of Cardiology
| | - Justin L Grodin
- University of Texas Southwestern Medical Center, Dallas, TX, Division of Cardiology
| | - S Susan Hedayati
- University of Texas Southwestern Medical Center, Dallas, TX, Division of Nephrology
- Stony Brook University, Renaissance School of Medicine, Stony Brook, NY, Division of Nephrology and Hypertension
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Carroll AM, Farr M, Russell SD, Schlendorf KH, Truby LK, Gilotra NA, Vader JM, Patel CB, DeVore AD. Beyond Stage C: Considerations in the Management of Patients with Heart Failure Progression and Gaps in Evidence. J Card Fail 2023; 29:818-831. [PMID: 36958390 DOI: 10.1016/j.cardfail.2023.02.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 02/07/2023] [Accepted: 02/24/2023] [Indexed: 03/25/2023]
Abstract
Despite treatment with contemporary medical therapies for chronic heart failure (HF), there has been an increase in the prevalence of patients progressing to more advanced disease. Patients progressing to and living at the interface of severe Stage C and Stage D HF are underrepresented in clinical trials, and there is a lack of high-quality evidence to guide clinical decision making. For patients with a severe HF phenotype, the medical therapies used for patients with a less advanced stage of illness are often no longer tolerated nor provide adequate clinical stability. The limited data on these patients highlights the need to increase formal research characterizing this high-risk population. This review summarizes existing clinical trial data on and incorporates our considerations for approaches to the medical management of patients advanced "beyond Stage C" HF.
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Affiliation(s)
- Aubrie M Carroll
- Department of Medicine, Division of Cardiology, Duke University Medical Center, Durham, NC, USA
| | - Maryjane Farr
- Department of Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Stuart D Russell
- Department of Medicine, Division of Cardiology, Duke University Medical Center, Durham, NC, USA
| | - Kelly H Schlendorf
- Department of Medicine, Division of Cardiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Lauren K Truby
- Department of Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Nisha A Gilotra
- Department of Medicine, Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Justin M Vader
- Department of Medicine, Division of Cardiology, Washington University, St Louis, MO, USA
| | - Chetan B Patel
- Department of Medicine, Division of Cardiology, Duke University Medical Center, Durham, NC, USA
| | - Adam D DeVore
- Department of Medicine, Division of Cardiology, Duke University Medical Center, Durham, NC, USA.
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Cascino TM, Colvin M, Lanfear DE, Richards B, Khalatbari S, Mann DL, Taddei-Peters WC, Jeffries N, Watkins DC, Stewart GC, Aaronson KD. Racial Inequities in Access to Ventricular Assist Device and Transplant Persist After Consideration for Preferences for Care: A Report From the REVIVAL Study. Circ Heart Fail 2023; 16:e009745. [PMID: 36259388 PMCID: PMC9851944 DOI: 10.1161/circheartfailure.122.009745] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Accepted: 08/24/2022] [Indexed: 01/22/2023]
Abstract
BACKGROUND Racial disparities in access to advanced therapies for heart failure (HF) patients are well documented, although the reasons remain uncertain. We sought to determine the association of race on utilization of ventricular assist device (VAD) and transplant among patients with access to care at VAD centers and if patient preferences impact the effect. METHODS We performed an observational cohort study of ambulatory chronic systolic HF patients with high-risk features and no contraindication to VAD enrolled at 21 VAD centers and followed for 2 years in the REVIVAL study (Registry Evaluation of Vital Information for VADs in Ambulatory Life). We used competing events cause-specific proportional hazard methodology with multiple imputation for missing data. The primary outcomes were (1) VAD/transplant and (2) death. The exposures of interest included race (Black or White), additional demographics, captured social determinants of health, clinician-assessed HF severity, patient-reported quality of life, preference for VAD, and desire for therapies. RESULTS The study included 377 participants, of whom 100 (26.5%) identified as Black. VAD or transplant was performed in 11 (11%) Black and 62 (22%) White participants, although death occurred in 18 (18%) Black and 36 (13%) White participants. Black race was associated with reduced utilization of VAD and transplant (adjusted hazard ratio, 0.45 [95% CI, 0.23-0.85]) without an increase in death. Preferences for VAD or life-sustaining therapies were similar by race and did not explain racial disparities. CONCLUSIONS Among patients receiving care by advanced HF cardiologists at VAD centers, there is less utilization of VAD and transplant for Black patients even after adjusting for HF severity, quality of life, and social determinants of health, despite similar care preferences. This residual inequity may be a consequence of structural racism and discrimination or provider bias impacting decision-making. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT01369407.
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Affiliation(s)
- Thomas M. Cascino
- University of Michigan, Division of Cardiovascular Disease, Ann Arbor, MI
| | - Monica Colvin
- University of Michigan, Division of Cardiovascular Disease, Ann Arbor, MI
| | | | - Blair Richards
- University of Michigan, Michigan Institute for Clinical and Health Research, Ann Arbor, MI
| | - Shokoufeh Khalatbari
- University of Michigan, Michigan Institute for Clinical and Health Research, Ann Arbor, MI
| | | | | | - Neal Jeffries
- National Heart, Lung, and Blood Institute, Bethesda, MD
| | | | | | - Keith D. Aaronson
- University of Michigan, Division of Cardiovascular Disease, Ann Arbor, MI
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Identifying potential candidates for advanced heart failure therapies using an interpretable machine learning algorithm. J Heart Lung Transplant 2022; 41:1781-1789. [PMID: 36192320 DOI: 10.1016/j.healun.2022.08.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 08/19/2022] [Accepted: 08/29/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Systems level barriers to heart failure (HF) care limit access to HF advanced therapies (heart transplantation, left ventricular assist devices). There is a need for automated systems that can help clinicians ensure patients with HF are evaluated for HF advanced therapies at the appropriate time to optimize outcomes. METHODS We performed a retrospective study using the REVIVAL (Registry Evaluation of Vital Information for VADs in Ambulatory Life) and INTERMACS (Interagency Registry for Mechanically Assisted Circulatory Support) registries. We developed a novel machine learning model based on principles of tropical geometry and fuzzy logic that can accommodate clinician knowledge and provide recommendations regarding need for advanced therapies evaluations that are accessible to end-users. RESULTS The model was trained and validated using data from 4,694 HF patients. When initiated with clinical knowledge from HF and transplant cardiologists, the model achieved an F1 score of 43.8%, recall of 51.1%, and precision of 46.9%. The model achieved comparable performance compared with other commonly used machine learning models. Importantly, our model was 1 of only 3 models providing transparent and parsimonious clinical rules, significantly outperforming the other 2 models. Eleven clinical rules were extracted from the model which can be leveraged in clinical practice. CONCLUSIONS A machine learning model capable of accepting clinical knowledge and making accessible recommendations was trained to identify patients with advanced HF. While this model was developed for HF care, the methodology has multiple potential uses in other important clinical applications.
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Blanding W, Kilic A. Demise of HVAD: The Only Constant is Change. J Thorac Cardiovasc Surg 2022; 164:1945-1947. [DOI: 10.1016/j.jtcvs.2022.02.004] [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: 11/02/2021] [Revised: 01/20/2022] [Accepted: 02/01/2022] [Indexed: 10/19/2022]
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Kittleson MM, Ambardekar AV, Stevenson LW, Gilotra NA, Shah P, Ewald GA, Thibodeau JT, Stehlik J, Palardy M, Estep JD, Cascino TM, Baldwin JT, Jeffries N, Khalatbari S, Yosef M, Peters WT, Richards B, Mann DL, Aaronson KD, Stewart GC. An early relook identifies high-risk trajectories in ambulatory advanced heart failure. J Heart Lung Transplant 2022; 41:104-112. [PMID: 34629234 PMCID: PMC8742755 DOI: 10.1016/j.healun.2021.09.003] [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: 07/06/2021] [Accepted: 09/07/2021] [Indexed: 01/03/2023] Open
Abstract
INTRODUCTION Patients with ambulatory advanced heart failure (HF) are increasingly considered for durable mechanical circulatory support (MCS) and heart transplantation and their effective triage requires careful assessment of the clinical trajectory. METHODS REVIVAL, a prospective, observational study, enrolled 400 ambulatory advanced HF patients from 21 MCS/transplant centers in 2015-2016. Study design included a clinical re-assessment of Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) profile within 120 days after enrollment. The prognostic impact of a worsening INTERMACS Profile assigned by the treating physician was assessed at 1 year after the Early Relook. RESULTS Early Relook was done in 325 of 400 patients (81%), of whom 24% had a worsened INTERMACS Profile, associated with longer HF history and worse baseline INTERMACS profile, but no difference in baseline LVEF (median 0.20), 6-minute walk, quality of life, or other baseline parameters. Early worsening predicted higher rate of the combined primary endpoint of death, urgent MCS, or urgent transplant by 1 year after Early Relook, (28% vs 15%), with hazard ratio 2.2 (95% CI 1.2- 3.8; p = .006) even after adjusting for baseline INTERMACS Profile and Seattle HF Model score. Deterioration to urgent MCS occurred in 14% vs 5% (p = .006) during the year after Early Relook. CONCLUSIONS Early Relook identifies worsening of INTERMACS Profile in a significant population of ambulatory advanced HF, who had worse outcomes over the subsequent year. Early reassessment of ambulatory advanced HF patients should be performed to better define the trajectory of illness and inform triage to advanced therapies.
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Affiliation(s)
| | | | - Lynne W. Stevenson
- Section of Advanced Heart Failure and Transplant Cardiology, Division of Cardiovascular Medicine, Vanderbilt University Medical Center Nashville, TN
| | - Nisha A. Gilotra
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Palak Shah
- Heart Failure & Transplantation, Inova Heart and Vascular Institute, Falls Church, VA
| | - Gregory A. Ewald
- Department of Medicine, Division of Cardiology, Washington University School of Medicine, St Louis, MO
| | - Jennifer T. Thibodeau
- Division of Cardiology, The University of Texas Southwestern Medical Center, Dallas, TX
| | - Josef Stehlik
- Division of Cardiovascular Medicine, University of Utah Health, University of Utah School of Medicine, Salt Lake City, UT
| | - Maryse Palardy
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, MI
| | - Jerry D. Estep
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH
| | - Thomas M. Cascino
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, MI
| | | | - Neal Jeffries
- Center for Devices and Radiological Health, Food and Drug Administration, Silver Spring, MD
| | - Shokoufeh Khalatbari
- Michigan Institute for Clinical and Health Research, University of Michigan, Ann Arbor, MI
| | - Matheos Yosef
- Michigan Institute for Clinical and Health Research, University of Michigan, Ann Arbor, MI
| | - Wendy Taddei Peters
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD
| | - Blair Richards
- Michigan Institute for Clinical and Health Research, University of Michigan, Ann Arbor, MI
| | - Douglas L. Mann
- Department of Medicine, Division of Cardiology, Washington University School of Medicine, St Louis, MO
| | - Keith D. Aaronson
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, MI
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Lala A, Shah P, Khalatbari S, Yosef M, Mountis MM, Robinson SW, Lanfear DE, Estep JD, Jeffries N, Taddei-Peters WC, Stevenson LW, Richards B, Mann DL, Mancini DM, Stewart GC, Aaronson KD. Frailty Measures of Patient-reported Activity and Fatigue May Predict 1-year Outcomes in Ambulatory Advanced Heart Failure: A Report From the REVIVAL Registry. J Card Fail 2021; 28:765-774. [PMID: 34961663 DOI: 10.1016/j.cardfail.2021.10.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 10/30/2021] [Accepted: 10/30/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND The Fried Frailty Phenotype predicts adverse outcomes in geriatric populations, but has not been well-studied in advanced heart failure (HF). The Registry Evaluation of Vital Information for Ventricular Assist Devices (VADs) in Ambulatory Life (REVIVAL) study prospectively collected frailty measures in patients with advanced HF to determine relevant assessments and their impact on clinical outcomes. METHODS AND RESULTS HF-Fried Frailty was defined by 5 baseline components (1 point each): (1) weakness: hand grip strength less than 25% of body weight; (2) slowness based on time to walk 15 feet; (3) weight loss of more than 10 lbs in the past year; (4) inactivity; and (5) exhaustion, both assessed by the Kansas City Cardiomyopathy Questionnaire. A score of 0 or 1 was deemed nonfrail, 2 prefrail, and 3 or greater was considered frail. The primary composite outcome was durable mechanical circulatory support implantation, cardiac transplant or death at 1 year. Event-free survival for each group was determined by the Kaplan-Meier method and the hazard of prefrailty and frailty were compared with nonfrailty with proportional hazards modeling. Among 345 patients with all 5 frailty domains assessed, frailty was present in 17%, prefrailty in 40%, and 43% were nonfrail, with 67% (n = 232) meeting the criteria based on inactivity and 54% (n = 186) for exhaustion. Frail patients had an increased risk of the primary composite outcome (unadjusted hazard ratio [HR] 2.82, 95% confidence interval [CI] 1.52-5.24; adjusted HR 3.41, 95% CI 1.79-6.52), as did prefrail patients (unadjusted HR 1.97, 95% CI 1.14-3.41; adjusted HR 2.11, 95% CI 1.21-3.66) compared with nonfrail patients, however, the predictive value of HF-Fried Frailty criteria was modest (Harrel's C-statistic of 0.603, P = .004). CONCLUSIONS The HF-Fried Frailty criteria had only modest predictive power in identifying ambulatory patients with advanced HF at high risk for durable mechanical circulatory support, transplant, or death within 1 year, driven primarily by assessments of inactivity and exhaustion. Focus on these patient-reported measures may better inform clinical trajectories in this population.
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Affiliation(s)
- Anuradha Lala
- Zena and Weil Cardiovascular Institute, Mount Sinai Hospital, Icahn School of Medicine, New York, New York; Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York.
| | - Palak Shah
- Heart Failure, Mechanical Circulatory Support and Transplant, Inova Heart and Vascular Institute, Falls Church, Virginia
| | - Shokoufeh Khalatbari
- Michigan Institute for Clinical and Health Research, University of Michigan, Ann Arbor, Michigan
| | - Matheos Yosef
- Michigan Institute for Clinical and Health Research, University of Michigan, Ann Arbor, Michigan
| | - Maria M Mountis
- Division of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio
| | | | - David E Lanfear
- Heart and Vascular Institute, Henry Ford Hospital, Detroit, Michigan
| | - Jerry D Estep
- Division of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Neal Jeffries
- National Heart, Lung, and Blood Institute, Bethesda, Maryland
| | | | - Lynne W Stevenson
- Department of Medicine, Division of Cardiology, Vanderbilt University, Nashville, Tennessee
| | - Blair Richards
- Michigan Institute for Clinical and Health Research, University of Michigan, Ann Arbor, Michigan
| | - Douglas L Mann
- Division of Cardiovascular Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Donna M Mancini
- Zena and Weil Cardiovascular Institute, Mount Sinai Hospital, Icahn School of Medicine, New York, New York; Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Garrick C Stewart
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Keith D Aaronson
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan
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Gilotra NA, Pamboukian SV, Mountis M, Robinson SW, Kittleson M, Shah KB, Forde-McLean RC, Haas DC, Horstmanshof DA, Jorde UP, Russell SD, Taddei-Peters WC, Jeffries N, Khalatbari S, Spino CA, Richards B, Yosef M, Mann DL, Stewart GC, Aaronson KD, Grady KL. Caregiver Health-Related Quality of Life, Burden, and Patient Outcomes in Ambulatory Advanced Heart Failure: A Report From REVIVAL. J Am Heart Assoc 2021; 10:e019901. [PMID: 34250813 PMCID: PMC8483456 DOI: 10.1161/jaha.120.019901] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Background Heart failure (HF) imposes significant burden on patients and caregivers. Longitudinal data on caregiver health-related quality of life (HRQOL) and burden in ambulatory advanced HF are limited. Methods and Results Ambulatory patients with advanced HF (n=400) and their participating caregivers (n=95) enrolled in REVIVAL (Registry Evaluation of Vital Information for VADs [Ventricular Assist Devices] in Ambulatory Life) were followed up for 24 months, or until patient death, left ventricular assist device implantation, heart transplantation, or loss to follow-up. Caregiver HRQOL (EuroQol Visual Analog Scale) and burden (Oberst Caregiving Burden Scale) did not change significantly from baseline to follow-up. At time of caregiver enrollment, better patient HRQOL by Kansas City Cardiomyopathy Questionnaire was associated with better caregiver HRQOL (P=0.007) and less burden by both time spent (P<0.0001) and difficulty (P=0.0007) of caregiving tasks. On longitudinal analyses adjusted for baseline values, better patient HRQOL (P=0.034) and being a married caregiver (P=0.016) were independently associated with better caregiver HRQOL. Patients with participating caregivers (versus without) were more likely to prefer left ventricular assist device therapy over time (odds ratio, 1.43; 95% CI, 1.03-1.99; P=0.034). Among patients with participating caregivers, those with nonmarried (versus married) caregivers were at higher composite risk of HF hospitalization, death, heart transplantation or left ventricular assist device implantation (hazard ratio, 2.99; 95% CI, 1.29-6.96; P=0.011). Conclusions Patient and caregiver characteristics may impact their HRQOL and other health outcomes over time. Understanding the patient-caregiver relationship may better inform medical decision making and outcomes in ambulatory advanced HF.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | - Wendy C Taddei-Peters
- Division of Cardiovascular Sciences National Heart, Lung, and Blood Institute Bethesda MD
| | - Neal Jeffries
- Division of Cardiovascular Sciences National Heart, Lung, and Blood Institute Bethesda MD
| | - Shokoufeh Khalatbari
- University of MichiganMichigan Institute for Clinical and Health Research Ann Arbor MI
| | | | - Blair Richards
- University of MichiganMichigan Institute for Clinical and Health Research Ann Arbor MI
| | - Matheos Yosef
- University of MichiganMichigan Institute for Clinical and Health Research Ann Arbor MI
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10
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Ambulatory advanced heart failure patients: timing of mechanical circulatory support - delaying the inevitable? Curr Opin Cardiol 2021; 36:186-197. [PMID: 33395078 DOI: 10.1097/hco.0000000000000831] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Current indications for continuous-flow left ventricular assist device (cfLVAD) implantation is for patients in cardiogenic shock or inotrope-dependent advanced heart failure. Risk stratification of noninotrope dependent ambulatory advanced heart failure patients is a subject of registries designed to help shared-decision making by clinicians and patients regarding the optimal timing of mechanical circulatory support (MCS). RECENT FINDINGS The Registry Evaluation of Vital Information for VADs in Ambulatory Life enrolled ambulatory noninotrope dependent advanced systolic heart failure patients who had 25% annualized risk of death, MCS, or heart transplantation (HT). Freedom from composite clinical outcome at 1-year follow-up was 23.5% for the entire cohort. Seattle Heart Failure Model Score and Natriuretic pepides were predictors with modest discriminatory power. Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) profile 4 patients had the highest risk (3.7-fold) of death, MCS or HT compared to INTERMACS profile 7. SUMMARY We propose individualized risk stratification for noninotrope dependent ambulatory advanced heart failure patients and include serial changes in end-organ function, nutritional parameters, frailty assessment, echocardiographic and hemodynamic data. The clinical journey of a patient with advanced heart failure should be tracked and discussed at each clinic visit for shared decision-making regarding timing of cfLVAD.
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Lala A, Shah KB, Lanfear DE, Thibodeau JT, Palardy M, Ambardekar AV, McNamara DM, Taddei-Peters WC, Baldwin JT, Jeffries N, Khalatbari S, Spino C, Richards B, Mann DL, Stewart GC, Aaronson KD, Mancini DM. Predictive Value of Cardiopulmonary Exercise Testing Parameters in Ambulatory Advanced Heart Failure. JACC-HEART FAILURE 2021; 9:226-236. [PMID: 33549559 DOI: 10.1016/j.jchf.2020.11.008] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 11/03/2020] [Accepted: 11/12/2020] [Indexed: 11/17/2022]
Abstract
OBJECTIVES This study sought to determine cardiopulmonary exercise (CPX) predictors of the combined outcome of durable mechanical circulatory support (MCS), transplantation, or death at 1 year among patients with ambulatory advanced heart failure (HF). BACKGROUND Optimal CPX predictors of outcomes in contemporary ambulatory advanced HF patients are unclear. METHODS REVIVAL (Registry Evaluation of Vital Information for ventricular assist devices [VADs] in Ambulatory Life) enrolled 400 systolic HF patients, INTERMACS (Interagency Registry for Mechanically Assisted Circulatory Support) profiles 4-7. CPX was performed by 273 subjects 2 ± 1 months after study enrollment. Discriminative power of maximal (peak oxygen consumption [peak VO2]; VO2 pulse, circulatory power [CP]; peak systolic blood pressure • peak VO2], peak end-tidal pressure CO2 [PEtCO2], and peak Borg scale score) and submaximal CPX parameters (ventilatory efficiency [VE/VCO2 slope]; VO2 at anaerobic threshold [VO2AT]; and oxygen uptake efficiency slope [OUES]) to predict the composite outcome were assessed by univariate and multivariate Cox regression and Harrell's concordance statistic. RESULTS At 1 year, there were 39 events (6 transplants, 15 deaths, 18 MCS implantations). Peak VO2, VO2AT, OUES, peak PEtCO2, and CP were higher in the no-event group (all p < 0.001), whereas VE/VCO2 slope was lower (p < 0.0001); respiratory exchange ratio was not different. CP (hazard ratio [HR]: 0.89; p = 0.001), VE/VCO2 slope (HR: 1.05; p = 0.001), and peak Borg scale score (HR: 1.20; p = 0.005) were significant predictors on multivariate analysis (model C-statistic: 0.80). CONCLUSIONS Among patients with ambulatory advanced HF, the strongest maximal and submaximal CPX predictor of MCS implantation, transplantation, or death at 1 year were CP and VE/VCO2, respectively. The patient-reported measure of exercise effort (Borg scale score) contributed substantially to the prediction of outcomes, a surprising and novel finding that warrants further investigation. (Registry Evaluation of Vital Information for VADs in Ambulatory Life [REVIVAL]; NCT01369407).
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Affiliation(s)
- Anuradha Lala
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA; Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Keyur B Shah
- Department of Medicine, Division of Cardiology, Virginia Commonwealth University, Richmond, Virginia, USA
| | - David E Lanfear
- Heart and Vascular Institute, Henry Ford Hospital, Detroit, Michigan, USA
| | - Jennifer T Thibodeau
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Maryse Palardy
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | | | - Dennis M McNamara
- Department of Medicine, Division of Cardiology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Wendy C Taddei-Peters
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, Maryland, USA
| | | | - Neal Jeffries
- Center for Devices and Radiological Health, Food and Drug Administration, Silver Spring, Maryland, USA
| | - Shokoufeh Khalatbari
- Michigan Institute for Clinical and Health Research, University of Michigan, Ann Arbor, Michigan, USA
| | - Cathie Spino
- Department of Biostatistics, University of Michigan, Ann Arbor, Michigan, USA
| | - Blair Richards
- Michigan Institute for Clinical and Health Research, University of Michigan, Ann Arbor, Michigan, USA
| | - Douglas L Mann
- Cardiovascular Division, Washington University School of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Garrick C Stewart
- Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Keith D Aaronson
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Donna M Mancini
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA; Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
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12
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Cascino TM, Kittleson MM, Lala A, Stehlik J, Palardy M, Pamboukian SV, Ewald GA, Mountis MM, Horstmanshof DA, Robinson SW, Shah P, Jorde UP, McLean RC, Richards B, Khalatbari S, Spino C, Taddei-Peters WC, Grady KL, Mann DL, Stevenson LW, Stewart GC, Aaronson KD. Comorbid Conditions and Health-Related Quality of Life in Ambulatory Heart Failure Patients: REVIVAL (Registry Evaluation of Vital Information for VADs in Ambulatory Life REVIVAL). Circ Heart Fail 2020; 13:e006858. [PMID: 32418478 DOI: 10.1161/circheartfailure.119.006858] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Patients with heart failure (HF) often have multiple chronic conditions that may impact health-related quality of life (HRQOL) despite HF therapy. We sought to determine the association between noncardiac comorbidities and HRQOL in ambulatory patients with advanced HF. METHODS Baseline data from 373 subjects in REVIVAL (Registry Evaluation of Vital Information for Ventricular Assist Devices in Ambulatory Life) were analyzed using multivariable general linear models to evaluate the relationship between comorbidities and HRQOL (EuroQol Visual Analogue Scale, EQ-5D-3L Index Score, and Kansas City Cardiomyopathy Questionnaire). The primary independent variables were a comorbidity index (sum of 14 noncardiac conditions), a residual comorbidity index (without depression), and depression alone. The median (25th to 75th percentile) number of comorbidities was 3 (2-4). RESULTS Increasing comorbidity burden was associated with a reduction in generic (EQ-5D Index, P=0.005) and HF-specific (Kansas City Cardiomyopathy Questionnaire, P=0.001) HRQOL. The residual comorbidity index was not associated with HRQOL when depression included in the model independently, while depression was associated with HRQOL across all measures. Participants with depression (versus without) scored on average 13 points (95% CI, 8-17) lower on the EuroQol Visual Analogue Scale, 0.15 points (95% CI, 0.12-0.18) lower on the EQ-5D Index, and 24.9 points (95% CI, 21.2-28.5) lower on the Kansas City Cardiomyopathy Questionnaire overall summary score. CONCLUSIONS While noncardiac comorbidities were prevalent in ambulatory advanced HF patients, only depression was associated with decreased generic and HF-specific HRQOL. Other than depression, the presence of noncardiac comorbidities should not impact expected gains in HRQOL following ventricular assist device implantation, provided the conditions are not a contraindication to implant. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT01369407.
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Affiliation(s)
- Thomas M Cascino
- Division of Cardiovascular Disease, University of Michigan, Ann Arbor (T.M.C., M.P., K.D.A.)
| | | | | | | | - Maryse Palardy
- Division of Cardiovascular Disease, University of Michigan, Ann Arbor (T.M.C., M.P., K.D.A.)
| | | | - Gregory A Ewald
- Washington University School of Medicine, St. Louis, MO (G.A.E., D.L.M.)
| | | | | | | | - Palak Shah
- Inova Heart and Vascular Institute, Falls Church, VA (P.S.)
| | | | | | - Blair Richards
- Michigan Institute for Clinical and Health Research, University of Michigan, Ann Arbor (B.R., S.K., C.S.)
| | - Shokoufeh Khalatbari
- Michigan Institute for Clinical and Health Research, University of Michigan, Ann Arbor (B.R., S.K., C.S.)
| | - Cathie Spino
- Michigan Institute for Clinical and Health Research, University of Michigan, Ann Arbor (B.R., S.K., C.S.).,University of Michigan School of Public Health, Ann Arbor (C.S.)
| | | | | | - Douglas L Mann
- Washington University School of Medicine, St. Louis, MO (G.A.E., D.L.M.)
| | | | | | - Keith D Aaronson
- Division of Cardiovascular Disease, University of Michigan, Ann Arbor (T.M.C., M.P., K.D.A.)
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13
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Stehlik J, Mountis M, Haas D, Palardy M, Ambardekar AV, Estep JD, Ewald G, Russell SD, Robinson S, Jorde U, Taddei-Peters WC, Jeffries N, Richards B, Khalatbari S, Spino C, Baldwin JT, Mann D, Stewart GC, Aaronson KD. Quality of life and treatment preference for ventricular assist device therapy in ambulatory advanced heart failure: A report from the REVIVAL study. J Heart Lung Transplant 2019; 39:27-36. [PMID: 31822442 DOI: 10.1016/j.healun.2019.11.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 11/13/2019] [Accepted: 11/14/2019] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND The Registry Evaluation of Vital Information for Ventricular Assist Devices (VADs) in Ambulatory Life study is a prospective multicenter cohort of 400 ambulatory patients with advanced chronic systolic heart failure (HF). The aim of the study is to better understand disease trajectory and optimal timing of advanced HF therapies. We examined patient health-related quality of life (HRQOL) data collected at enrollment and their association with patient treatment preferences for VAD placement. METHODS Baseline assessment of HRQOL included the Kansas City Cardiomyopathy Questionnaire (KCCQ) and the EuroQol EQ-5D-3L Visual Analogue Scale (VAS), along with patient self-assessment of remaining life (PSARL). Descriptive statistics were used to present baseline HRQOL data and Spearman correlation tests to assess the association between KCCQ, VAS, and VAD treatment preference with patient clinical characteristics of interest. RESULTS The median age was 60 years, 75% were male, and the median left ventricular ejection fraction was 20%. The median (25th percentile, 75th percentile), baseline KCCQ summary score was 64 (48, 78), VAS score 65 (50, 75), and PSARL 7 years (5, 10). There were statistically significant associations of baseline KCCQ and VAS with New York Heart Association class and Interagency Registry of Mechanically Assisted Circulatory Support profile (p < 0.005 for all comparisons). Baseline KCCQ and VAS revealed a modest association with PSARL (correlation = 0.45 and 0.35, respectively; p < 0.001), and many patients were overly optimistic about their expected survival. VAD treatment preference was associated with KCCQ scores (p < 0.031), but the absolute differences were small. VAD treatment preference was independent of other key clinical characteristics such as subject age, VAS, and PSARL. CONCLUSIONS We found a lack of strong association between HRQOL and patient preference for VAD therapy. Better understanding of patients' perceptions of their illness and how this relates to HRQOL outcomes, clinician risk assessment, and patient decision-making is needed. This may in turn allow better guidance toward available HF therapies in this vulnerable population.
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Affiliation(s)
- Josef Stehlik
- University of Utah School of Medicine, Salt Lake City, Utah.
| | | | - Donald Haas
- Abington - Jefferson Health, Abington, Pennsylvania
| | - Maryse Palardy
- University of Michigan Medical School, Ann Arbor, Michigan
| | | | | | - Gregory Ewald
- Washington University School of Medicine, St. Louis, Missouri
| | | | | | - Ulrich Jorde
- Montefiore Medical Center, New York City, New York
| | | | - Neal Jeffries
- National Heart, Lung, and Blood Institute, Bethesda, Maryland
| | - Blair Richards
- University of Michigan, Michigan Institute for Clinical and Health Research, Ann Arbor, Michigan
| | - Shokoufeh Khalatbari
- University of Michigan, Michigan Institute for Clinical and Health Research, Ann Arbor, Michigan
| | - Catherine Spino
- University of Michigan School of Public Health, Ann Arbor, Michigan
| | | | - Douglas Mann
- Washington University School of Medicine, St. Louis, Missouri
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