1
|
Sperry BW, Zein RE, Fendler TJ, Sauer AJ, Khumri TM, Magalski A, Austin BA, Safley D, Kao AC. Stabilization of Rapidly Progressive Cardiac Allograft Vasculopathy Using mTOR Inhibition After Heart Transplantation. J Card Fail 2024; 30:613-617. [PMID: 37992800 DOI: 10.1016/j.cardfail.2023.10.483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 10/26/2023] [Accepted: 10/27/2023] [Indexed: 11/24/2023]
Abstract
BACKGROUND Inhibition of the mammalian target of rapamycin (mTor) pathway after heart transplantation has been associated with reduced progression of coronary allograft vasculopathy (CAV). The application of low-dose mTOR inhibition in the setting of modern immunosuppression, including tacrolimus, remains an area of limited exploration. METHODS This retrospective study included patients who received heart transplantation between January 2009 and January 2019 and had baseline, 1-year and 2-3-year coronary angiography with intravascular ultrasound (IVUS). Intimal thickness in 5 segments along the left anterior descending artery was compared across imaging time points in patients who were transitioned to low-dose mTOR inhibitor (sirolimus) vs standard treatment with mycophenolate on a background of tacrolimus. Long-term adverse cardiovascular outcomes (revascularization, severe CAV, retransplant, and cardiovascular death) were also assessed. RESULTS Among 216 patients (mean age 51.5 ± 11.9 years, 77.8% men, 80.1% white), 81 individuals (37.5%) were switched to mTOR inhibition. mTOR inhibition was associated with a reduction in intimal thickness by 0.05 mm (95% CI 0.02-0.07; P < 0.001). This reduction was driven by patients who met the criteria for rapidly progressive CAV 1-year post-transplant (0.12 mm; P = 0.016 for interaction). After a median follow-up of 8.6 (IQR 6.6-11) years, 40 patients had major adverse cardiovascular outcomes. The use of mTOR inhibitors was not significantly associated with cardiovascular outcomes (P = 0.669). CONCLUSION Transitioning patients after heart transplantation to an immunosuppression regimen composed of low-dose mTOR inhibition and tacrolimus was associated with a lack of progression of CAV, particularly in those with rapidly progressive CAV at 1 year, but not with long-term cardiovascular outcomes.
Collapse
Affiliation(s)
- Brett W Sperry
- Saint Luke's Mid America Heart Institute, Kansas City, MO; University of Missouri-Kansas City School of Medicine, Kansas City, MO.
| | - Rayan El Zein
- University of Missouri-Kansas City School of Medicine, Kansas City, MO
| | - Timothy J Fendler
- Saint Luke's Mid America Heart Institute, Kansas City, MO; University of Missouri-Kansas City School of Medicine, Kansas City, MO
| | - Andrew J Sauer
- Saint Luke's Mid America Heart Institute, Kansas City, MO; University of Missouri-Kansas City School of Medicine, Kansas City, MO
| | - Taiyeb M Khumri
- Saint Luke's Mid America Heart Institute, Kansas City, MO; University of Missouri-Kansas City School of Medicine, Kansas City, MO
| | - Anthony Magalski
- Saint Luke's Mid America Heart Institute, Kansas City, MO; University of Missouri-Kansas City School of Medicine, Kansas City, MO
| | - Bethany A Austin
- Saint Luke's Mid America Heart Institute, Kansas City, MO; University of Missouri-Kansas City School of Medicine, Kansas City, MO
| | - David Safley
- Saint Luke's Mid America Heart Institute, Kansas City, MO; University of Missouri-Kansas City School of Medicine, Kansas City, MO
| | - Andrew C Kao
- Saint Luke's Mid America Heart Institute, Kansas City, MO; University of Missouri-Kansas City School of Medicine, Kansas City, MO
| |
Collapse
|
2
|
Arnold SV, Fendler TJ. Reply: Methodologic Challenges of Propensity Score-Based Analyses. JACC Heart Fail 2023; 11:1649. [PMID: 37940220 DOI: 10.1016/j.jchf.2023.08.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Accepted: 08/22/2023] [Indexed: 11/10/2023]
|
3
|
Arnold SV, Silverman DN, Gosch K, Nassif ME, Infeld M, Litwin S, Meyer M, Fendler TJ. Beta-Blocker Use and Heart Failure Outcomes in Mildly Reduced and Preserved Ejection Fraction. JACC Heart Fail 2023; 11:893-900. [PMID: 37140513 DOI: 10.1016/j.jchf.2023.03.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 03/27/2023] [Accepted: 03/28/2023] [Indexed: 05/05/2023]
Abstract
BACKGROUND Although studies consistently show that beta-blockers reduce morbidity and mortality in patients with reduced ejection fraction (EF), data are inconsistent in patients with heart failure with mildly reduced ejection fraction (HFmrEF) and suggest potential negative effects in heart failure with preserved ejection fraction (HFpEF). OBJECTIVES The purpose of this study was to examine the association of beta-blockers with heart failure (HF) hospitalization and death in patients with HF and EF ≥40% METHODS: Beta-blocker use was assessed at first encounter in outpatients ≥65 years of age with HFmrEF and HFpEF in the U.S. PINNACLE Registry (2013-2017). The associations of beta-blockers with HF hospitalization, death, and the composite of HF hospitalization/death were assessed using propensity-score adjusted multivariable Cox regression models, including interactions of EF × beta-blocker use. RESULTS Among 435,897 patients with HF and EF ≥40% (HFmrEF, n = 75,674; HFpEF = 360,223), 289,377 (66.4%) were using a beta-blocker at first encounter; more commonly in patients with HFmrEF vs HFpEF (77.7% vs 64.0%; P < 0.001). There were significant interactions between EF × beta-blocker use for HF hospitalization, death, and composite of HF hospitalization/death (P < 0.001 for all), with higher risk with beta-blocker use as EF increased. Beta-blockers were associated with decreased risk of HF hospitalization and death in patients with HFmrEF but a lack of survival benefit and a higher risk of HF hospitalization in patients with HFpEF, particularly when EF was >60%. CONCLUSIONS In a large, real-world, propensity score-adjusted cohort of older outpatients with HF and EF ≥40%, beta-blocker use was associated with a higher risk of HF hospitalization as EF increased, with potential benefit in patients with HFmrEF and potential risk in patients with higher EF (particularly >60%). Further studies are needed to understand the appropriateness of beta-blocker use in patients with HFpEF in the absence of compelling indications.
Collapse
Affiliation(s)
- Suzanne V Arnold
- Saint Luke's Mid America Heart Institute and University of Missouri-Kansas City School of Medicine, Kansas City, Missouri, USA.
| | - Daniel N Silverman
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina, USA; Division of Cardiology, Department of Medicine, Ralph H. Johnson Veterans Administration Medical Center, Charleston, South Carolina, USA
| | - Kensey Gosch
- Saint Luke's Mid America Heart Institute and University of Missouri-Kansas City School of Medicine, Kansas City, Missouri, USA
| | - Michael E Nassif
- Saint Luke's Mid America Heart Institute and University of Missouri-Kansas City School of Medicine, Kansas City, Missouri, USA
| | - Margaret Infeld
- Department of Medicine, University of Vermont Larner College of Medicine, Burlington, Vermont, USA
| | - Sheldon Litwin
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina, USA; Division of Cardiology, Department of Medicine, Ralph H. Johnson Veterans Administration Medical Center, Charleston, South Carolina, USA
| | - Markus Meyer
- Lillehei Heart Institute, Department of Medicine, University of Minnesota College of Medicine, Minneapolis, Minnesota, USA
| | - Timothy J Fendler
- Saint Luke's Mid America Heart Institute and University of Missouri-Kansas City School of Medicine, Kansas City, Missouri, USA
| |
Collapse
|
4
|
Turk A, Khariton Y, Kao A, Khumri T, Sperry B, Magalski A, Austin B, Lawhorn S, Vodnala D, Nassif M, Fendler TJ. Use Of Implantable Pulmonary Artery Pressure Monitoring To Guide Care Of Patients With Ambulatory Heart Failure; The First Three Years In A Real World, Single Center Experience. J Card Fail 2022. [DOI: 10.1016/j.cardfail.2022.03.113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
|
5
|
Harhash AA, Kennedy KF, Fendler TJ, Khumri TM, Nassif ME, Magalski A, Sperry BW. Comparison of Outcomes Among Patients With Cardiogenic Shock Admitted on Weekends Versus Weekdays. Am J Cardiol 2021; 144:20-25. [PMID: 33417875 DOI: 10.1016/j.amjcard.2020.12.061] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 12/18/2020] [Accepted: 12/22/2020] [Indexed: 11/30/2022]
Abstract
Cardiogenic shock (CS) is associated with high mortality and often requires involvement of a multidisciplinary provider team to deliver timely care. Care coordination is more difficult on weekends, which may lead to a delay in care. We sought to assess the effect of weekend admissions on outcomes in patients admitted with CS. Patients admitted with CS were identified from 2005 to 2014 in the National Inpatient Sample using ICD9 code 785.51. Baseline demographics, in-hospital procedures, and outcomes were obtained and compared by day of admission. A multivariable model was used to assess the impact of weekend admission on in-hospital mortality. A total of 875,054 CS admissions were identified (age 67.4 ± 15.1 years, 40.2% female, 72.1% Caucasian), with 23% of patients being admitted on weekends. Baseline co-morbidities were similar between groups. Weekend admissions were associated with higher in-hospital mortality (40.6% vs 37.5%) and cardiac arrest (20.3% vs 18.1%, p < 0.001 for both) consistently over the study period. Use of temporary and permanent mechanical support devices and heart transplantation were slightly less common for weekend admissions. In a multivariable model adjusting for relevant confounders, weekend admission was associated with a 10% increased mortality in patients with CS. In conclusion, patients with CS admitted on weekends had higher in-hospital mortality and were slightly less likely to receive mechanical support and advanced therapies compared with those admitted on weekdays. Future studies and health system initiatives should focus on rectifying these disparities with around-the-clock multidisciplinary coordinated care for CS.
Collapse
Affiliation(s)
- Ahmed A Harhash
- Saint Luke's Mid America Heart Institute, Kansas City, Missouri; University of Missouri-Kansas City, Kansas City, Missouri
| | | | - Timothy J Fendler
- Saint Luke's Mid America Heart Institute, Kansas City, Missouri; University of Missouri-Kansas City, Kansas City, Missouri
| | - Taiyeb M Khumri
- Saint Luke's Mid America Heart Institute, Kansas City, Missouri; University of Missouri-Kansas City, Kansas City, Missouri
| | - Michael E Nassif
- Saint Luke's Mid America Heart Institute, Kansas City, Missouri; University of Missouri-Kansas City, Kansas City, Missouri
| | - Anthony Magalski
- Saint Luke's Mid America Heart Institute, Kansas City, Missouri; University of Missouri-Kansas City, Kansas City, Missouri
| | - Brett W Sperry
- Saint Luke's Mid America Heart Institute, Kansas City, Missouri; University of Missouri-Kansas City, Kansas City, Missouri.
| |
Collapse
|
6
|
Sammour Y, Dezorzi C, Austin BA, Borkon AM, Everley MP, Fendler TJ, Khumri TM, Lawhorn SL, Nassif ME, Vodnala D, Magalski A, Kao AC, Sperry BW. PCSK9 Inhibitors in Heart Transplant Patients: Safety, Efficacy, and Angiographic Correlates. J Card Fail 2021; 27:812-815. [PMID: 33753241 DOI: 10.1016/j.cardfail.2021.02.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Revised: 02/08/2021] [Accepted: 02/23/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Statins are recommended in heart transplant patients, but are sometimes poorly tolerated. Alternative agents are often considered including proprotein convertase subtilisin/kexin type-9 inhibitors (PCSK9i). We sought to investigate the use of PCSK9i after heart transplantation. METHODS AND RESULTS We identified patients who received a heart transplant from 1999 to 2019 and were started on PCSK9i at our institution. Clinical, laboratory, and coronary angiography with intravascular ultrasound results were compared. Among 65 patients initiated on PCSK9i (48 for statin intolerance and 17 for refractory hyperlipidemia), the median time from transplant was 5.5 years (interquartile range [IQR], 2.8-9.9 years) with a median PCSK9 treatment duration of 1.6 years (IQR, 0.8-3.2 years) and 80% still on treatment. Evolocumab was used in 73.8%, alirocumab in 12.3%, and both in 13.8% owing to insurance coverage. All patients required prior authorization; initial denial occurred in 18.5% and 32.3% had denials in subsequent years. The median low-density lipoprotein cholesterol decreased from 130 mg/dL (IQR, 102-148 mg/dL) to 55 mg/dL (IQR, 35-74 mg/dL) after starting PCSK9i (P < .001), with 72% of patients achieving a low-density lipoprotein cholesterol of <70 mg/dL after treatment. There were also significant reductions of total cholesterol, non-high-density lipoprotein cholesterol, total/high-density lipoprotein cholesterol ratio, and triglycerides, with a modest increase in high-density lipoprotein cholesterol. These changes were durable at latest follow-up. In 33 patients with serial coronary angiography and intravascular ultrasound, PCSK9i were associated with stable coronary plaque thickness and lumen area. CONCLUSIONS Among heart transplant recipients, PCSK9i are effective in lowering cholesterol levels and stabilizing coronary intimal hyperplasia with minimal side effects. Despite favorable effects, access and affordability remain a challenge.
Collapse
Affiliation(s)
- Yasser Sammour
- Saint Luke's Mid America Heart Institute and the University of Kanas City-Missouri, Kansas City, MO
| | - Christopher Dezorzi
- Saint Luke's Mid America Heart Institute and the University of Kanas City-Missouri, Kansas City, MO
| | - Bethany A Austin
- Saint Luke's Mid America Heart Institute and the University of Kanas City-Missouri, Kansas City, MO
| | - A Michael Borkon
- Saint Luke's Mid America Heart Institute and the University of Kanas City-Missouri, Kansas City, MO
| | - Mark P Everley
- Saint Luke's Mid America Heart Institute and the University of Kanas City-Missouri, Kansas City, MO
| | - Timothy J Fendler
- Saint Luke's Mid America Heart Institute and the University of Kanas City-Missouri, Kansas City, MO
| | - Taiyeb M Khumri
- Saint Luke's Mid America Heart Institute and the University of Kanas City-Missouri, Kansas City, MO
| | - Stephanie L Lawhorn
- Saint Luke's Mid America Heart Institute and the University of Kanas City-Missouri, Kansas City, MO
| | - Michael E Nassif
- Saint Luke's Mid America Heart Institute and the University of Kanas City-Missouri, Kansas City, MO
| | - Deepthi Vodnala
- Saint Luke's Mid America Heart Institute and the University of Kanas City-Missouri, Kansas City, MO
| | - Anthony Magalski
- Saint Luke's Mid America Heart Institute and the University of Kanas City-Missouri, Kansas City, MO
| | - Andrew C Kao
- Saint Luke's Mid America Heart Institute and the University of Kanas City-Missouri, Kansas City, MO
| | - Brett W Sperry
- Saint Luke's Mid America Heart Institute and the University of Kanas City-Missouri, Kansas City, MO.
| |
Collapse
|
7
|
Gondi KT, Kao A, Linard J, Austin BA, Everley MP, Fendler TJ, Khumri T, Lawhorn SL, Magalski A, Nassif ME, Sperry BW, Vodnala D, Borkon AM. Single-center utilization of donor-derived cell-free DNA testing in the management of heart transplant patients. Clin Transplant 2021; 35:e14258. [PMID: 33606316 DOI: 10.1111/ctr.14258] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2021] [Revised: 02/02/2021] [Accepted: 02/13/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Gene expression profiling (GEP) and donor-derived cell-free DNA (dd-cfDNA) are useful in acute rejection (AR) surveillance in orthotopic heart transplant (OHT) patients. We report a single-center experience of combined GEP and dd-cfDNA testing for AR surveillance. METHODS GEP and dd-cfDNA are tested together starting at 2 months post-OHT. After 6 months, combined testing was obtained before scheduled endomyocardial biopsy (EMB), and EMB was canceled with a negative dd-cfDNA. This approach was compared to using a GEP-only approach, where EMB was canceled with a negative GEP. We evaluated for frequency of EMB cancellation with dd-cfDNA usage. RESULTS A total of 153 OHT patients over a 13-month period underwent 495 combined GEP/dd-cfDNA tests. 82.2% of dd-cfDNA tests were below threshold. Above threshold results identified high-risk patients who developed AR. 378 combined tests ≥6 months post-OHT resulted in cancellation of 83.9% EMBs as opposed to 71.2% with GEP surveillance alone. There were 2 acute cellular and 2 antibody-mediated rejection episodes, and no significant AR ≥6 months. CONCLUSION Routine dd-cfDNA testing alongside GEP testing yielded a significant reduction in EMB volume by re-classifying GEP (+) patients into a lower risk group, without reduction in AR detection. The addition of dd-cfDNA identified patients at higher risk for AR.
Collapse
Affiliation(s)
- Keerthi T Gondi
- University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA
| | - Andrew Kao
- Department of Cardiovascular Medicine, Mid America Heart Institute, Saint Luke's Health System Kansas City, Kansas City, MO, USA
| | - Jodie Linard
- Department of Cardiac Transplant, Mid America Heart Institute, Saint Luke's Health System Kansas City, Kansas City, MO, USA
| | - Bethany A Austin
- Department of Cardiovascular Medicine, Mid America Heart Institute, Saint Luke's Health System Kansas City, Kansas City, MO, USA
| | - Mark P Everley
- Department of Cardiovascular Medicine, Mid America Heart Institute, Saint Luke's Health System Kansas City, Kansas City, MO, USA
| | - Timothy J Fendler
- Department of Cardiovascular Medicine, Mid America Heart Institute, Saint Luke's Health System Kansas City, Kansas City, MO, USA
| | - Taiyeb Khumri
- Department of Cardiovascular Medicine, Mid America Heart Institute, Saint Luke's Health System Kansas City, Kansas City, MO, USA
| | - Stephanie L Lawhorn
- Department of Cardiovascular Medicine, Mid America Heart Institute, Saint Luke's Health System Kansas City, Kansas City, MO, USA
| | - Anthony Magalski
- Department of Cardiovascular Medicine, Mid America Heart Institute, Saint Luke's Health System Kansas City, Kansas City, MO, USA
| | - Michael E Nassif
- Department of Cardiovascular Medicine, Mid America Heart Institute, Saint Luke's Health System Kansas City, Kansas City, MO, USA
| | - Brett W Sperry
- Department of Cardiovascular Medicine, Mid America Heart Institute, Saint Luke's Health System Kansas City, Kansas City, MO, USA
| | - Deepthi Vodnala
- Department of Cardiovascular Medicine, Mid America Heart Institute, Saint Luke's Health System Kansas City, Kansas City, MO, USA
| | - A Michael Borkon
- Department of Cardiothoracic Surgery, Mid America Heart Institute, Saint Luke's Health System Kansas City, Kansas City, MO, USA
| |
Collapse
|
8
|
Fendler TJ, Allen LA, Matlock DD. Did You Forget to Assess Cognition in Your Patient With Heart Failure, and Does It Matter? J Card Fail 2021; 27:295-296. [PMID: 33632392 DOI: 10.1016/j.cardfail.2021.01.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 01/11/2021] [Indexed: 12/15/2022]
Affiliation(s)
- Timothy J Fendler
- Saint Luke's Mid America Heart Institute/University of Missouri-Kansas City, Kansas City, Missouri
| | - Larry A Allen
- Adult and Child Consortium for Outcomes Research and Delivery Science, Aurora; Division of Cardiology, University of Colorado School of Medicine, Aurora
| | - Daniel D Matlock
- Adult and Child Consortium for Outcomes Research and Delivery Science, Aurora; Veterans Affairs, Eastern Colorado Geriatric Research Education and Clinical Center, Denver; Division of Geriatric Medicine, University of Colorado School of Medicine, Aurora, Colorado.
| |
Collapse
|
9
|
Sperry BW, Qarajeh R, Omer MA, Brandt H, Safley D, Borkon AM, Everley MP, Fendler TJ, Khumri TM, Lawhorn SL, Magalski A, Nassif ME, Vodnala D, Kao AC, Austin BA. Influence of Donor Transmitted and Rapidly Progressive Coronary Vascular Disease on Long-Term Outcomes After Heart Transplantation: A Contemporary Intravascular Ultrasound Analysis. J Card Fail 2021; 27:464-472. [PMID: 33358960 DOI: 10.1016/j.cardfail.2020.12.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 12/14/2020] [Accepted: 12/16/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Donor-transmitted atherosclerosis (DTA) and rapidly progressive cardiac allograft vasculopathy (CAV) at 1 year are intravascular ultrasound (IVUS)-derived measures shown to predict adverse cardiovascular outcomes in the setting of early generation immunosuppressive agents. Given the paucity of data on the prognostic value of IVUS-derived measurements in the current era, we sought to explore their association with adverse outcomes after heart transplantation. METHODS AND RESULTS This is a retrospective cohort analysis of patients who underwent heart transplantation at our center between January 2009 and June 2016 with baseline and 1-year IVUS. Five IVUS sections were prospectively analyzed for intimal thickness and lumen area. DTA was defined as maximum intimal thickness of 0.5 mm or greater at baseline, and rapidly progressive CAV as an increase in maximum intimal thickness by 0.5 mm or more at 1 year. Our primary analysis assessed the relationship of IVUS and other clinical data on a composite outcome: coronary intervention, CAV stage 2 or 3 (defined by the International Society for Heart and Lung Transplantation 2010 nomenclature), or cardiovascular death. Among 249 patients (mean age 51.0 ± 12.2 years and 74.3% male) included in the analysis, DTA was detected in 118 patients (51.4%). Over a median follow-up of 6.1 years (interquartile range 4.2-8.0 years), 45 patients met the primary end point (23 percutaneous coronary intervention, 11 CAV 2 or 3, and 11 cardiovascular deaths as first event). DTA and rapidly progressive CAV were not associated with the primary end point, all-cause mortality, or retransplantation. In an additional analysis including post-transplant events, incident rejection was strongly associated with poor outcomes, although cytomegalovirus infection was not. CONCLUSIONS In this contemporary cohort, IVUS-derived DTA and rapidly progressive CAV were not associated with medium- to long-term adverse events after heart transplantation.
Collapse
Affiliation(s)
- Brett W Sperry
- Saint Luke's Mid America Heart Institute, Kansas City, Missouri; University of Missouri-Kansas City School of Medicine, Kansas City, Missouri.
| | - Raed Qarajeh
- University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
| | - Mohamed A Omer
- University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
| | - Hunter Brandt
- Saint Luke's Mid America Heart Institute, Kansas City, Missouri; University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
| | - David Safley
- Saint Luke's Mid America Heart Institute, Kansas City, Missouri; University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
| | - A Michael Borkon
- Saint Luke's Mid America Heart Institute, Kansas City, Missouri; University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
| | - Mark P Everley
- Saint Luke's Mid America Heart Institute, Kansas City, Missouri; University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
| | - Timothy J Fendler
- Saint Luke's Mid America Heart Institute, Kansas City, Missouri; University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
| | - Taiyeb M Khumri
- Saint Luke's Mid America Heart Institute, Kansas City, Missouri; University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
| | - Stephanie L Lawhorn
- Saint Luke's Mid America Heart Institute, Kansas City, Missouri; University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
| | - Anthony Magalski
- Saint Luke's Mid America Heart Institute, Kansas City, Missouri; University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
| | - Michael E Nassif
- Saint Luke's Mid America Heart Institute, Kansas City, Missouri; University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
| | - Deepthi Vodnala
- Saint Luke's Mid America Heart Institute, Kansas City, Missouri; University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
| | - Andrew C Kao
- Saint Luke's Mid America Heart Institute, Kansas City, Missouri; University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
| | - Bethany A Austin
- Saint Luke's Mid America Heart Institute, Kansas City, Missouri; University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
| |
Collapse
|
10
|
Grodzinsky A, Fendler TJ, Howell G, Gupta S, Lawhorn S, Bhardwaj B, Sharma A, Taduru SS, Sperry B, Saeed IM. Evolution of Diagnostic and Treatment Patterns of Cardiac Sarcoidosis. Mo Med 2020; 117:543-547. [PMID: 33311786 PMCID: PMC7721427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Cardiac sarcoidosis (CS) may impart substantial morbidity and mortality, and novel imaging modalities are now available to aid in early diagnosis of this clinically silent disease. A better understanding of the clinical experience with CS is important. Twenty-eight patients were diagnosed with the aid of multimodality imaging techniques and were treated by a multidisciplinary team. Demographics, symptomatology, imaging, and therapeutic interventions were compiled from our referral center. In patients with CS, nuclear and MR techniques were often the first studies performed. Echocardiographic findings differed widely. Immunosuppressive therapy and cardiac devices were frequently used. Importantly, isolated CS was not an infrequent finding.
Collapse
Affiliation(s)
- Anna Grodzinsky
- Anna Grodzinsky, MD, MSc, Timothy J. Fendler, MD, Gregory Howell, MD, Sanjaya Gupta, MD, Stephanie Lawhorn, MD, MSMA member since 2014, Brett Sperry, MD, Siva Sagar Taduru, MD and Ibrahim M. Saeed, MD, are with the University of Missouri - Kansas City School of Medicine and Saint Luke's Mid-America Heart Institute Hospital in Kansas City, Missouri. Bhaskar Bhardwaj, MD, MSMA member since 2020, is with the University of Missouri - Columbia Department of Cardiovascular Disease, and Akshit Sharma, MD, is with the University of Kansas Medical Center Division of Cardiovascular Disease
| | - Timothy J Fendler
- Anna Grodzinsky, MD, MSc, Timothy J. Fendler, MD, Gregory Howell, MD, Sanjaya Gupta, MD, Stephanie Lawhorn, MD, MSMA member since 2014, Brett Sperry, MD, Siva Sagar Taduru, MD and Ibrahim M. Saeed, MD, are with the University of Missouri - Kansas City School of Medicine and Saint Luke's Mid-America Heart Institute Hospital in Kansas City, Missouri. Bhaskar Bhardwaj, MD, MSMA member since 2020, is with the University of Missouri - Columbia Department of Cardiovascular Disease, and Akshit Sharma, MD, is with the University of Kansas Medical Center Division of Cardiovascular Disease
| | - Gregory Howell
- Anna Grodzinsky, MD, MSc, Timothy J. Fendler, MD, Gregory Howell, MD, Sanjaya Gupta, MD, Stephanie Lawhorn, MD, MSMA member since 2014, Brett Sperry, MD, Siva Sagar Taduru, MD and Ibrahim M. Saeed, MD, are with the University of Missouri - Kansas City School of Medicine and Saint Luke's Mid-America Heart Institute Hospital in Kansas City, Missouri. Bhaskar Bhardwaj, MD, MSMA member since 2020, is with the University of Missouri - Columbia Department of Cardiovascular Disease, and Akshit Sharma, MD, is with the University of Kansas Medical Center Division of Cardiovascular Disease
| | - Sanjaya Gupta
- Anna Grodzinsky, MD, MSc, Timothy J. Fendler, MD, Gregory Howell, MD, Sanjaya Gupta, MD, Stephanie Lawhorn, MD, MSMA member since 2014, Brett Sperry, MD, Siva Sagar Taduru, MD and Ibrahim M. Saeed, MD, are with the University of Missouri - Kansas City School of Medicine and Saint Luke's Mid-America Heart Institute Hospital in Kansas City, Missouri. Bhaskar Bhardwaj, MD, MSMA member since 2020, is with the University of Missouri - Columbia Department of Cardiovascular Disease, and Akshit Sharma, MD, is with the University of Kansas Medical Center Division of Cardiovascular Disease
| | - Stephanie Lawhorn
- Anna Grodzinsky, MD, MSc, Timothy J. Fendler, MD, Gregory Howell, MD, Sanjaya Gupta, MD, Stephanie Lawhorn, MD, MSMA member since 2014, Brett Sperry, MD, Siva Sagar Taduru, MD and Ibrahim M. Saeed, MD, are with the University of Missouri - Kansas City School of Medicine and Saint Luke's Mid-America Heart Institute Hospital in Kansas City, Missouri. Bhaskar Bhardwaj, MD, MSMA member since 2020, is with the University of Missouri - Columbia Department of Cardiovascular Disease, and Akshit Sharma, MD, is with the University of Kansas Medical Center Division of Cardiovascular Disease
| | - Bhaskar Bhardwaj
- Anna Grodzinsky, MD, MSc, Timothy J. Fendler, MD, Gregory Howell, MD, Sanjaya Gupta, MD, Stephanie Lawhorn, MD, MSMA member since 2014, Brett Sperry, MD, Siva Sagar Taduru, MD and Ibrahim M. Saeed, MD, are with the University of Missouri - Kansas City School of Medicine and Saint Luke's Mid-America Heart Institute Hospital in Kansas City, Missouri. Bhaskar Bhardwaj, MD, MSMA member since 2020, is with the University of Missouri - Columbia Department of Cardiovascular Disease, and Akshit Sharma, MD, is with the University of Kansas Medical Center Division of Cardiovascular Disease
| | - Akshit Sharma
- Anna Grodzinsky, MD, MSc, Timothy J. Fendler, MD, Gregory Howell, MD, Sanjaya Gupta, MD, Stephanie Lawhorn, MD, MSMA member since 2014, Brett Sperry, MD, Siva Sagar Taduru, MD and Ibrahim M. Saeed, MD, are with the University of Missouri - Kansas City School of Medicine and Saint Luke's Mid-America Heart Institute Hospital in Kansas City, Missouri. Bhaskar Bhardwaj, MD, MSMA member since 2020, is with the University of Missouri - Columbia Department of Cardiovascular Disease, and Akshit Sharma, MD, is with the University of Kansas Medical Center Division of Cardiovascular Disease
| | - Siva Sagar Taduru
- Anna Grodzinsky, MD, MSc, Timothy J. Fendler, MD, Gregory Howell, MD, Sanjaya Gupta, MD, Stephanie Lawhorn, MD, MSMA member since 2014, Brett Sperry, MD, Siva Sagar Taduru, MD and Ibrahim M. Saeed, MD, are with the University of Missouri - Kansas City School of Medicine and Saint Luke's Mid-America Heart Institute Hospital in Kansas City, Missouri. Bhaskar Bhardwaj, MD, MSMA member since 2020, is with the University of Missouri - Columbia Department of Cardiovascular Disease, and Akshit Sharma, MD, is with the University of Kansas Medical Center Division of Cardiovascular Disease
| | - Brett Sperry
- Anna Grodzinsky, MD, MSc, Timothy J. Fendler, MD, Gregory Howell, MD, Sanjaya Gupta, MD, Stephanie Lawhorn, MD, MSMA member since 2014, Brett Sperry, MD, Siva Sagar Taduru, MD and Ibrahim M. Saeed, MD, are with the University of Missouri - Kansas City School of Medicine and Saint Luke's Mid-America Heart Institute Hospital in Kansas City, Missouri. Bhaskar Bhardwaj, MD, MSMA member since 2020, is with the University of Missouri - Columbia Department of Cardiovascular Disease, and Akshit Sharma, MD, is with the University of Kansas Medical Center Division of Cardiovascular Disease
| | - Ibrahim M Saeed
- Anna Grodzinsky, MD, MSc, Timothy J. Fendler, MD, Gregory Howell, MD, Sanjaya Gupta, MD, Stephanie Lawhorn, MD, MSMA member since 2014, Brett Sperry, MD, Siva Sagar Taduru, MD and Ibrahim M. Saeed, MD, are with the University of Missouri - Kansas City School of Medicine and Saint Luke's Mid-America Heart Institute Hospital in Kansas City, Missouri. Bhaskar Bhardwaj, MD, MSMA member since 2020, is with the University of Missouri - Columbia Department of Cardiovascular Disease, and Akshit Sharma, MD, is with the University of Kansas Medical Center Division of Cardiovascular Disease
| |
Collapse
|
11
|
Sammour Y, Austin BA, Borkon M, Everley MP, Fendler TJ, Khumri TM, Lawhorn SL, Magalski A, Nassif ME, Vodnala D, Kao AC, Sperry BW. Safety and Effectiveness of PCSK9 Inhibitors in Orthotopic Heart Transplant Patients. J Card Fail 2020. [DOI: 10.1016/j.cardfail.2020.09.071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|
12
|
Fendler TJ, McIlvennan CK, Matlock DD, Thompson JS, Chaussee EL, Dunlay SM, LaRue SJ, Raymer DS, Spertus JA, Lewis EF, Patel CB, Walsh MN, Allen LA. Exploring differences between patients who accept, decline, and are deemed ineligible for left ventricular assist device implantation as destination therapy. J Heart Lung Transplant 2020; 39:721-724. [PMID: 32376277 DOI: 10.1016/j.healun.2020.03.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Revised: 03/10/2020] [Accepted: 03/27/2020] [Indexed: 10/24/2022] Open
Affiliation(s)
- Timothy J Fendler
- Health Outcomes Research, University of Missouri-Kansas City, Kansas City, Missouri; Department of Cardiology, Saint Luke's Mid America Heart Institute, Kansas City, Missouri.
| | - Colleen K McIlvennan
- Adult and Child Consortium for Outcomes Research and Delivery Science; Division of Cardiology, University of Colorado School of Medicine, Aurora, Colorado
| | - Daniel D Matlock
- Adult and Child Consortium for Outcomes Research and Delivery Science; Veterans Affairs, Eastern Colorado Geriatric Research Education and Clinical Center, Denver, Colorado; Division of Geriatric Medicine, University of Colorado School of Medicine, Aurora, Colorado
| | | | - Erin L Chaussee
- Adult and Child Consortium for Outcomes Research and Delivery Science; Department of Biostatistics and Informatics, University of Colorado School of Public Health, Aurora, Colorado
| | - Shannon M Dunlay
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Shane J LaRue
- Department of Internal Medicine, Cardiovascular Division, Washington University School of Medicine, St Louis, Missouri
| | - David S Raymer
- Adult and Child Consortium for Outcomes Research and Delivery Science
| | - John A Spertus
- Health Outcomes Research, University of Missouri-Kansas City, Kansas City, Missouri; Department of Cardiology, Saint Luke's Mid America Heart Institute, Kansas City, Missouri
| | | | - Chetan B Patel
- Department of Medicine, Cardiology Division, Duke University Medical Center, Durham, North Carolina
| | - Mary Norine Walsh
- Division of Cardiology, St Vincent Heart Center, Indianapolis, Indiana
| | - Larry A Allen
- Adult and Child Consortium for Outcomes Research and Delivery Science; Division of Cardiology, University of Colorado School of Medicine, Aurora, Colorado
| |
Collapse
|
13
|
Perman SM, Beaty BL, Daugherty SL, Havranek EP, Haukoos JS, Juarez-Colunga E, Bradley SM, Fendler TJ, Chan PS. Do Sex Differences Exist in the Establishment of "Do Not Attempt Resuscitation" Orders and Survival in Patients Successfully Resuscitated From In-Hospital Cardiac Arrest? J Am Heart Assoc 2020; 9:e014200. [PMID: 32063126 PMCID: PMC7070220 DOI: 10.1161/jaha.119.014200] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Background Women have higher utilization of “do not attempt resuscitation” (DNAR) orders during treatment for critical illness. Occurrence of sex differences in the establishment of DNAR orders after resuscitation from in‐hospital cardiac arrest is unknown. Whether differences in DNAR use by sex lead to disparities in survival remains unclear. Methods and Results We identified 71 820 patients with return of spontaneous circulation (ROSC) after in‐hospital cardiac arrest from the Get With The Guidelines–Resuscitation registry. Multivariable models evaluated the association between de novo DNAR (anytime after ROSC, within 12 hours of ROSC, or within 72 hours of ROSC) by sex and the association between sex and survival to discharge accounting for DNAR. All models accounted for clustering of patients within hospital and adjusted for demographic and cardiac arrest characteristics. The cohort included 30 454 (42.4%) women, who were slightly more likely than male participants to establish DNAR orders anytime after ROSC (45.0% versus 43.5%; adjusted relative risk: 1.15 [95% CI, 1.10–1.20]; P<0.0001). Of those with DNAR orders, women were more likely to be DNAR status within the first 12 hours (51.8% versus 46.5%; adjusted relative risk: 1.40 [95% CI, 1.30–1.52]; P<0.0001) and within 72 hours after ROSC (75.9% versus 70.9%; adjusted relative risk: 1.35 [95% CI, 1.26–1.45]; P<0.0001). However, no difference in survival to hospital discharge between women and men (34.5% versus 36.7%; adjusted relative risk: 1.00 [95% CI, 0.99–1.02]; P=0.74) was appreciated. Conclusions In patients successfully resuscitated from in‐hospital cardiac arrest, there was no survival difference between men and women while accounting for DNAR. However, women had a higher rate of DNAR status early after resuscitation (<12 and <72 hours) in comparison to men.
Collapse
Affiliation(s)
- Sarah M Perman
- Department of Emergency Medicine University of Colorado, School of Medicine Aurora CO
| | - Brenda L Beaty
- Adult and Child Consortium for Health Outcomes Research and Delivery Science University of Colorado, School of Medicine Aurora CO
| | - Stacie L Daugherty
- Adult and Child Consortium for Health Outcomes Research and Delivery Science University of Colorado, School of Medicine Aurora CO.,Division of Cardiology University of Colorado School of Medicine Aurora CO
| | | | - Jason S Haukoos
- Department of Emergency Medicine University of Colorado, School of Medicine Aurora CO.,Department of Emergency Medicine Denver Health Medical Center Denver CO.,Department of Epidemiology Colorado School of Public Health Aurora CO
| | - Elizabeth Juarez-Colunga
- Adult and Child Consortium for Health Outcomes Research and Delivery Science University of Colorado, School of Medicine Aurora CO
| | - Steven M Bradley
- Minneapolis Heart Institute and Minneapolis Heart Institute Foundation Minneapolis MN
| | | | - Paul S Chan
- Department of Cardiology Mid America Heart Institute Kansas City MO
| | | |
Collapse
|
14
|
Affiliation(s)
- Timothy J. Fendler
- Department of Cardiology, St Luke’s Mid America Heart Institute, Kansas City, MO (T.J.F.)
| | - Shannon M. Dunlay
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (S.M.D.)
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN (S.M.D.)
| |
Collapse
|
15
|
Fendler TJ, Spertus JA, Kennedy KF, Chan PS. Association between hospital rates of early Do-Not-Resuscitate orders and favorable neurological survival among survivors of inhospital cardiac arrest. Am Heart J 2017; 193:108-116. [PMID: 29129249 DOI: 10.1016/j.ahj.2017.05.017] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Accepted: 05/15/2017] [Indexed: 12/21/2022]
Abstract
BACKGROUND Current guidelines recommend deferring prognostication for 48 to 72 hours after resuscitation from inhospital cardiac arrest. It is unknown whether hospitals vary in making patients who survive an arrest Do-Not-Resuscitate (DNR) early after resuscitation and whether a hospital's rate of early DNR is associated with its rate of favorable neurological survival. METHODS Within Get With the Guidelines-Resuscitation, we identified 24,899 patients from 236 hospitals who achieved return of spontaneous circulation (ROSC) after inhospital cardiac arrest between 2006 and 2012. Hierarchical models were constructed to derive risk-adjusted hospital rates of DNR status adoption ≤12 hours after ROSC and risk-standardized rates of favorable neurological survival (without severe disability; Cerebral Performance Category ≤2). The association between hospitals' rates of early DNR and favorable neurological survival was evaluated using correlation statistics. RESULTS Of 236 hospitals, 61.7% were academic, 83% had ≥200 beds, and 94% were urban. Overall, 5577 (22.4%) patients were made DNR ≤12 hours after ROSC. Risk-adjusted hospital rates of early DNR varied widely (7.1%-40.5%, median: 22.7% [IQR: 19.3%-26.1%]; median OR of 1.48). Significant hospital variation existed in risk-standardized rates of favorable neurological survival (3.5%-44.8%, median: 25.3% [IQR: 20.2%-29.4%]; median OR 1.72). Hospitals' risk-adjusted rates of early DNR were inversely correlated with their risk-standardized rates of favorable neurological survival (r=-0.179, P=.006). CONCLUSIONS Despite current guideline recommendations, many patients with inhospital cardiac arrest are made DNR within 12 hours after ROSC, and hospitals vary widely in rates of early DNR. Higher hospital rates of early DNR were associated with worse meaningful survival outcomes.
Collapse
Affiliation(s)
| | | | | | | | -
- Department of Cardiology, Saint Luke's Mid America Heart Institute, Kansas City, MO
| |
Collapse
|
16
|
Wordingham SE, McIlvennan CK, Fendler TJ, Behnken AL, Dunlay SM, Kirkpatrick JN, Swetz KM. Palliative Care Clinicians Caring for Patients Before and After Continuous Flow-Left Ventricular Assist Device. J Pain Symptom Manage 2017; 54:601-608. [PMID: 28711755 DOI: 10.1016/j.jpainsymman.2017.07.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Revised: 04/17/2017] [Accepted: 07/06/2017] [Indexed: 10/19/2022]
Abstract
Left ventricular assist devices (LVADs) are an available treatment option for carefully selected patients with advanced heart failure. Initially developed as a bridge to transplantation, LVADs are now also offered to patients ineligible for transplantation as destination therapy (DT). Individuals with a DT-LVAD will live the remainder of their lives with the device in place. Although survival and quality of life improve with LVADs compared with medical therapy, complications persist including bleeding, infection, and stroke. There has been increased emphasis on involving palliative care (PC) specialists in LVAD programs, specifically the DT-LVAD population, from the pre-implantation process through the end of life. Palliative care specialists are well poised to provide education, guidance, and support to patients, families, and clinicians throughout the LVAD journey. This article addresses the complexities of the LVAD population, describes key challenges faced by PC specialists, and discusses opportunities for building collaboration between PC specialists and LVAD teams.
Collapse
Affiliation(s)
| | | | | | | | | | | | - Keith M Swetz
- University of Alabama-Birmingham, Birmingham, Alabama, USA; Birmingham VA Medical Center, Birmingham, Alabama, USA.
| |
Collapse
|
17
|
Nassif ME, Fendler TJ, Spertus JA. Individualized Risk Estimates From Population Data: Should We Stop Creating Models and Start Engaging Patients? J Card Fail 2017; 23:278-279. [DOI: 10.1016/j.cardfail.2017.02.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Revised: 02/10/2017] [Accepted: 02/10/2017] [Indexed: 11/26/2022]
|
18
|
Fendler TJ, Nassif ME, Kennedy KF, Joseph SM, Silvestry SC, Ewald GA, LaRue SJ, Vader JM, Spertus JA, Arnold SV. Global Outcome in Patients With Left Ventricular Assist Devices. Am J Cardiol 2017; 119:1069-1073. [PMID: 28160976 DOI: 10.1016/j.amjcard.2016.12.014] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Revised: 12/19/2016] [Accepted: 12/19/2016] [Indexed: 12/01/2022]
Abstract
Left ventricular assist devices (LVADs) improve survival and quality of life (QOL) for most, but not all, patients with advanced heart failure. We described a broader definition of poor outcomes after LVAD, using a novel composite of death, QOL, and other major adverse events. We evaluated the frequency of poor global outcome at 1 year after LVAD among 164 patients (86% Interagency Registry for Mechanically Assisted Circulatory Support profile 1 to 2; shock or declining despite inotropes) at a high-volume center. Poor global outcome (comprising death, poor QOL [Kansas City Cardiomyopathy Questionnaire <45], recurrent heart failure [≥2 heart failure readmissions], or severe stroke) occurred in 58 patients (35%): 37 died, 17 had poor QOL, 3 had recurrent heart failure, and 1 had a severe stroke. Patients with poor global outcomes were more likely designated for destination therapy (46% vs 24%, p = 0.01), spent more days hospitalized per month alive (median [interquartile range] 18.6 [5.0 to 31.0] vs 3.7 [1.8 to 8.3], p <0.001), and had higher intracranial (12% vs 2%, p = 0.031) and gastrointestinal (44% vs 28%, p = 0.056) hemorrhage rates over the year after implant. Although LVADs often improve survival and QOL, ∼1/3 of high-acuity patients experienced a poor global outcome over the year after LVAD. In conclusion, composite outcomes may better capture events that matter to patients with LVADs and thus support informed decisions about pursuing LVAD therapy.
Collapse
Affiliation(s)
- Timothy J Fendler
- Department of Cardiovascular Outcomes Research, Saint Luke's Mid America Heart Institute, Kansas City, Missouri; Department of Cardiology, University of Missouri-Kansas City, Kansas City, Missouri.
| | - Michael E Nassif
- Department of Cardiovascular Outcomes Research, Saint Luke's Mid America Heart Institute, Kansas City, Missouri; Department of Cardiology, Washington University School of Medicine, Saint Louis, Missouri
| | - Kevin F Kennedy
- Department of Cardiovascular Outcomes Research, Saint Luke's Mid America Heart Institute, Kansas City, Missouri
| | - Susan M Joseph
- Department of Cardiology, Baylor University Medical Center, Dallas, Texas
| | - Scott C Silvestry
- Department of Cardiovascular Surgery, Florida Hospital Transplant Institute, Florida Hospital, Orlando, Florida
| | - Gregory A Ewald
- Department of Cardiology, Washington University School of Medicine, Saint Louis, Missouri
| | - Shane J LaRue
- Department of Cardiology, Washington University School of Medicine, Saint Louis, Missouri
| | - Justin M Vader
- Department of Cardiology, Washington University School of Medicine, Saint Louis, Missouri
| | - John A Spertus
- Department of Cardiovascular Outcomes Research, Saint Luke's Mid America Heart Institute, Kansas City, Missouri; Department of Cardiology, University of Missouri-Kansas City, Kansas City, Missouri
| | - Suzanne V Arnold
- Department of Cardiovascular Outcomes Research, Saint Luke's Mid America Heart Institute, Kansas City, Missouri; Department of Cardiology, University of Missouri-Kansas City, Kansas City, Missouri
| |
Collapse
|
19
|
Flint KM, Spertus JA, Tang F, Jones P, Fendler TJ, Allen LA. Association of global and disease-specific health status with outcomes following continuous-flow left ventricular assist device implantation. BMC Cardiovasc Disord 2017; 17:78. [PMID: 28288574 PMCID: PMC5348898 DOI: 10.1186/s12872-017-0510-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2016] [Accepted: 03/07/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The prognostic value of heart failure specific and global health status before and after left ventricular assist device (LVAD) implantation in the usual care setting is not well studied. METHODS We included 3,836 continuous-flow LVAD patients in the INTERMACS registry. Health status was measured pre-operatively and 3 months post-LVAD using the Kansas City Cardiomyopathy Questionnaire (KCCQ) and EuroQol visual analog scale (VAS). Primary outcomes were mortality/rehospitalization. Inverse propensity weighting was used to minimize bias from missing data. RESULTS Pre-operative global and heart failure-specific health status were very poor: KCCQ median 34.6 (IQR 21.4-50.5); VAS median 43 (interquartile range (IQR) 25-65). Health status measures improved 3 months after LVAD placement: KCCQ median 69.3 (IQR 54.2-82.3); VAS median 75 (IQR 60-85). Pre-operative health status was not associated with death (unadjusted HR for lowest vs. highest score quartiles: 1.09 (0.85-1.41) KCCQ; 1.12 (0.85-1.49) VAS) or rehospitalization (unadjusted HR 0.83 (0.72-0.96) KCCQ; 0.99 (0.85-1.16) VAS). Three-month KCCQ was associated with mortality (unadjusted HR 2.17 (1.47-3.21); VAS was not (1.43 (0.94-2.17). Three-month KCCQ added incremental discriminatory value to the HeartMate II Risk Score for death (c-stat 0.60 to 0.66); VAS did not (c-stat 0.59 to 0.60). Three-month health status was associated with rehospitalization (unadjusted HR 1.31 (1.15-1.57) KCCQ; 1.24 (1.05-1.46) VAS), but did not add incremental discriminatory value (c-stat 0.52 to 0.55 and 0.54, respectively). CONCLUSIONS These real-world data suggest that pre-operative health status has limited association with outcomes after LVAD. However, persistently low health status after surgery may independently signal higher risk for subsequent death. Further study is needed to determine the clinical utility of routinely collected health status data after LVAD implantation.
Collapse
Affiliation(s)
- Kelsey M. Flint
- Division of Cardiology, University of Colorado Denver School of Medicine, Aurora, Colorado; Center for Cardiovascular Outcomes Research, 12631 East 17th Ave,, B130, Aurora, CO 80045 Denver, USA
| | - John A. Spertus
- Saint Luke’s Mid America Heart Institute and University of Missouri - Kansas City, Kansas City, MO USA
| | - Fengming Tang
- Saint Luke’s Mid America Heart Institute and University of Missouri - Kansas City, Kansas City, MO USA
| | - Philip Jones
- Saint Luke’s Mid America Heart Institute and University of Missouri - Kansas City, Kansas City, MO USA
| | - Timothy J. Fendler
- Saint Luke’s Mid America Heart Institute and University of Missouri - Kansas City, Kansas City, MO USA
| | - Larry A. Allen
- Division of Cardiology, Section of Advanced Heart Failure and Transplantation, University of Colorado Denver School of Medicine, Aurora, Colorado; Center for Cardiovascular Outcomes Research, Denver, CO USA
| |
Collapse
|
20
|
Nassif ME, Spertus JA, Jones PG, Fendler TJ, Allen LA, Grady KL, Arnold SV. Abstract 055: Changes in Disease-specific versus Generic Health Status Measures After Left Ventricular Assist Device Implantation: Insights From INTERMACS. Circ Cardiovasc Qual Outcomes 2017. [DOI: 10.1161/circoutcomes.10.suppl_3.055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
The effects of left ventricular assist device (LVAD) therapy on quality of life (QoL) are typically assessed with a combination of heart failure (HF)-specific and generic QoL measures. A generic QoL measure is believed to be necessary to fully capture the QoL effects of LVADs, as non-cardiac factors, such as comorbidities or LVAD complications, may limit generic QoL despite improvement in HF QoL after LVAD. However, the frequency and drivers of this expected discrepancy between HF-specific and generic QoL measures after LVAD implant are not known.
Methods:
Patients who underwent LVAD implantation as part of the INTERMACS registry from 2012-14 were assessed prior to and 6 months after LVAD with the Kansas City Cardiomyopathy Questionnaire (KCCQ) and EQ-5D Visual Analog Scale (VAS) to measure HF-specific and generic QoL, respectively. Scores range from 0-100, and ~5 points indicates a clinically relevant change for both measures. Changes in scores were standardized by dividing by the standard deviation of the corresponding baseline score and were categorized as: <0 (worsening), 0 to <0.5 (small improvement), 0.5 to <1 (moderate improvement), and ≥1 (large improvement). Discordance was defined as a ≥2-category difference in standardized changes. Among patients who reported improvement in HF-QoL, multivariable logistic regression was used to examine factors associated with KCCQ-VAS discordance.
Results:
Among 1888 patients, the majority reported improvement in both HF-specific and generic QoL after LVAD, with mean changes in the KCCQ of 32.7 ± 25.0 and in the VAS of 27.6 ± 27.4. Among the 1539 patients (81.5%) with moderate/large improvement in KCCQ, 334 (21.7%) had discordant changes in generic QoL (i.e., VAS did not substantially increase despite improvement in KCCQ). In multivariable modeling, baseline VAS scores were the strongest predictor of future KCCQ-VAS discordance (OR 2.17 per +10 VAS, 95% CI 1.98-2.38). Post-LVAD complications were not associated with discordance.
Conclusion:
In a multicenter cohort of patients undergoing LVAD implant, most patients had substantial improvements in both CHF-specific and generic QoL. Discordance occurred in only ~1/5 of patients and was primarily observed among patients who reported good generic QoL prior to their LVAD (despite low KCCQ). Contrary to our expectations, non-cardiac comorbidities and LVAD complications were not associated with discordance. These results support the continued use of the KCCQ to monitor QoL before and after LVAD implantation but also highlight potential limitations of the VAS in fully capturing the QoL effects from LVADs.
Collapse
Affiliation(s)
- Michael E. Nassif
- Saint Lukes Mid America Heart Institute/Univ of Missouri Kansas City, Kansas City, MO
| | - John A Spertus
- Saint Lukes Mid America Heart Institute/Univ of Missouri Kansas City, Kansas City, MO
| | - Philip G Jones
- Saint Lukes Mid America Heart Institute/Univ of Missouri Kansas City, Kansas City, MO
| | - Timothy J. Fendler
- Saint Lukes Mid America Heart Institute/Univ of Missouri Kansas City, Kansas City, MO
| | - Larry A. Allen
- Univ of Colorado Sch of Medicine Anschutz Med Campus, Denver, CO
| | | | - Suzanne V Arnold
- Saint Lukes Mid America Heart Institute/Univ of Missouri Kansas City, Kansas City, MO
| |
Collapse
|
21
|
Flint KM, Schmiege SJ, Allen LA, Fendler TJ, Rumsfeld J, Bekelman D. Health Status Trajectories Among Outpatients With Heart Failure. J Pain Symptom Manage 2017; 53:224-231. [PMID: 27756621 DOI: 10.1016/j.jpainsymman.2016.08.018] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2016] [Revised: 08/11/2016] [Accepted: 08/26/2016] [Indexed: 10/20/2022]
Abstract
CONTEXT Health status (i.e., symptoms, function, and quality of life) is an important palliative care outcome in patients with heart failure; however, patterns of health status over time (i.e., trajectories) are not well described. OBJECTIVES The objective of this study was to identify health status trajectories in outpatients with heart failure and assess whether depression, symptom burden, or sense of peace predict health status trajectory. METHODS This is an observational study utilizing data from the Patient-Centered Disease Management for Heart Failure trial. Participants completed Kansas City Cardiomyopathy Questionnaires at baseline, three, six, and 12 months. Latent class growth analysis identified health status trajectories; multinomial logistic regression models identified predictors of trajectory membership. RESULTS Patients (n = 384) were primarily men (97%) and older (mean age 67.6 ± 10.1). Three health status trajectories were identified. All three trajectories improved at three months; however, the marked improvement health status trajectory (n = 19) showed progressive improvement over one year, whereas the poor (n = 119) and moderate (n = 246) health status trajectories had little change after three months. In adjusted analyses, worse baseline depression (odds ratio 1.10; 95% confidence interval 1.01-1.20), symptom burden (1.45; 1.15-1.83), and sense of peace (0.41; 0.22-0.75) predicted membership in the poor vs. moderate health status trajectory. CONCLUSION We identified three one-year health status trajectories in patients with heart failure, with the two most common trajectories characterized by early improvement followed by limited change. Future research should assess these findings in nonveterans and women and explore whether treatment of depression, high symptom burden, and low sense of peace leads to improved long-term heart failure health status trajectory.
Collapse
Affiliation(s)
- Kelsey M Flint
- Division of Cardiology, Department of Medicine, University of Colorado School of Medicine Anschutz Medical Campus, Aurora, Colorado, USA; Colorado Cardiovascular Outcomes Research Consortium, Denver, Colorado, USA.
| | - Sarah J Schmiege
- Department of Biostatistics and Informatics, Colorado School of Public Health, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Larry A Allen
- Colorado Cardiovascular Outcomes Research Consortium, Denver, Colorado, USA; Section of Advanced Heart Failure and Transplantation, Division of Cardiology, Department of Medicine, University of Colorado School of Medicine Anschutz Medical Campus, Aurora, Colorado, USA
| | - Timothy J Fendler
- Division of Cardiovascular Diseases, St. Luke's Mid-American Heart Institute, University of Missouri, Kansas City, Missouri, USA
| | - John Rumsfeld
- American College of Cardiology, Washington, District of Columbia, USA
| | - David Bekelman
- Colorado Cardiovascular Outcomes Research Consortium, Denver, Colorado, USA; VA Eastern Colorado Health Care System, Denver, Colorado, USA; Department of Medicine, Division of General Internal Medicine, University of Colorado School of Medicine Anschutz Medical Campus, Aurora, Colorado, USA
| |
Collapse
|
22
|
Arnold SV, Jones PG, Allen LA, Cohen DJ, Fendler TJ, Holtz JE, Aggarwal S, Spertus JA. Frequency of Poor Outcome (Death or Poor Quality of Life) After Left Ventricular Assist Device for Destination Therapy: Results From the INTERMACS Registry. Circ Heart Fail 2016; 9:e002800. [PMID: 27507111 PMCID: PMC4985017 DOI: 10.1161/circheartfailure.115.002800] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Accepted: 06/21/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND A left ventricular assist device (LVAD) improves survival and quality of life for many, but not all, patients with end-stage heart failure who are ineligible for transplantation. We sought to evaluate the frequency of poor outcomes using a novel composite measure that integrates quality of life with mortality. METHODS AND RESULTS Within the INTERMACS (Interagency Registry for Mechanically Assisted Circulatory Support) national registry, poor outcome was defined as death or an average Kansas City Cardiomyopathy Questionnaire <45 during the year after LVAD (persistently limiting heart failure symptoms and poor quality of life). Among 1638 patients with LVAD, 29.7% had a poor outcome, with death in 22.4% and persistently poor quality of life in 7.3%. Patients who had a poor outcome were more likely to have higher body mass indices (29.3 versus 28.2 kg/m(2); P=0.007), lower hemoglobin levels (11.1 versus 11.4 g/dL; P=0.005), previous cardiac surgery (47.8% versus 39.8%; P=0.004), history of cancer (13.8% versus 9.7%; P=0.025), severe diabetes mellitus (15.6% versus 11.5%; P=0.038), and poorer quality of life preimplant (Kansas City Cardiomyopathy Questionnaire scores: 29.8 versus 35.3; P<0.001). CONCLUSIONS Nearly one third of patients die or have a persistently poor quality of life during the year after LVAD. We identified several factors associated with a poor outcome, which may inform discussions before LVAD implantation to enable more realistic expectations of recovery.
Collapse
Affiliation(s)
- Suzanne V Arnold
- From the Saint Luke's Mid America Heart Institute, Kansas City, MO (S.V.A., P.G.J., D.J.C., T.J.F., S.A., J.A.S.); University of Missouri-Kansas City (S.V.A., D.J.C., T.J.F., J.A.S.); University of Colorado, Denver (L.A.A.); and University of Pittsburgh, PA (J.E.H.).
| | - Philip G Jones
- From the Saint Luke's Mid America Heart Institute, Kansas City, MO (S.V.A., P.G.J., D.J.C., T.J.F., S.A., J.A.S.); University of Missouri-Kansas City (S.V.A., D.J.C., T.J.F., J.A.S.); University of Colorado, Denver (L.A.A.); and University of Pittsburgh, PA (J.E.H.)
| | - Larry A Allen
- From the Saint Luke's Mid America Heart Institute, Kansas City, MO (S.V.A., P.G.J., D.J.C., T.J.F., S.A., J.A.S.); University of Missouri-Kansas City (S.V.A., D.J.C., T.J.F., J.A.S.); University of Colorado, Denver (L.A.A.); and University of Pittsburgh, PA (J.E.H.)
| | - David J Cohen
- From the Saint Luke's Mid America Heart Institute, Kansas City, MO (S.V.A., P.G.J., D.J.C., T.J.F., S.A., J.A.S.); University of Missouri-Kansas City (S.V.A., D.J.C., T.J.F., J.A.S.); University of Colorado, Denver (L.A.A.); and University of Pittsburgh, PA (J.E.H.)
| | - Timothy J Fendler
- From the Saint Luke's Mid America Heart Institute, Kansas City, MO (S.V.A., P.G.J., D.J.C., T.J.F., S.A., J.A.S.); University of Missouri-Kansas City (S.V.A., D.J.C., T.J.F., J.A.S.); University of Colorado, Denver (L.A.A.); and University of Pittsburgh, PA (J.E.H.)
| | - Jonathan E Holtz
- From the Saint Luke's Mid America Heart Institute, Kansas City, MO (S.V.A., P.G.J., D.J.C., T.J.F., S.A., J.A.S.); University of Missouri-Kansas City (S.V.A., D.J.C., T.J.F., J.A.S.); University of Colorado, Denver (L.A.A.); and University of Pittsburgh, PA (J.E.H.)
| | - Sanjeev Aggarwal
- From the Saint Luke's Mid America Heart Institute, Kansas City, MO (S.V.A., P.G.J., D.J.C., T.J.F., S.A., J.A.S.); University of Missouri-Kansas City (S.V.A., D.J.C., T.J.F., J.A.S.); University of Colorado, Denver (L.A.A.); and University of Pittsburgh, PA (J.E.H.)
| | - John A Spertus
- From the Saint Luke's Mid America Heart Institute, Kansas City, MO (S.V.A., P.G.J., D.J.C., T.J.F., S.A., J.A.S.); University of Missouri-Kansas City (S.V.A., D.J.C., T.J.F., J.A.S.); University of Colorado, Denver (L.A.A.); and University of Pittsburgh, PA (J.E.H.)
| |
Collapse
|
23
|
Shafiq A, Jang JS, Kureshi F, Fendler TJ, Gosch K, Jones PG, Cohen DJ, Bach R, Spertus JA. Predicting Likelihood for Coronary Artery Bypass Grafting After Non-ST-Elevation Myocardial Infarction: Finding the Best Prediction Model. Ann Thorac Surg 2016; 102:1304-11. [PMID: 27266420 DOI: 10.1016/j.athoracsur.2016.03.090] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Revised: 03/14/2016] [Accepted: 03/22/2016] [Indexed: 11/17/2022]
Abstract
BACKGROUND Up to half of patients with non-ST-elevation myocardial infarction (NSTEMI) do not receive dual antiplatelet therapy before angiography "pretreatment" because of the risk of increased bleeding if coronary artery bypass grafting (CABG) operation is needed. Several models have been published that predict the likelihood of CABG after NSTEMI, but they have not been independently validated. The purpose of this study was to validate these models and improve the best one. METHODS We studied patients with NSTEMI who were enrolled in the 24-center Translational Research Investigating Underlying Disparities in Acute Myocardial Infarction Patients' Health Status (TRIUMPH) registry between 2005 and 2008. Previous CABG prediction models were assessed using c-statistics and calibration assessments to determine the best model. Variables from TRIUMPH likely to be associated with CABG were tested to see whether they could improve the best model's performance. RESULTS Among 2,473 patients with NSTEMI, 11.8% underwent in-hospital CABG. C-statistics for the Modified Thrombolysis in Myocardial Infarction, Treat Angina With Aggrastat and Determine the Cost of Therapy With an Invasive or Conservative Strategy-Thrombolysis in Myocardial Infarction 18, Poppe, and Global Risk of Acute Coronary Events (GRACE) models were 0.54, 0.61, 0.61, and 0.62, respectively. The GRACE model showed the best discrimination and calibration. From the TRIUMPH registry, preselected variables were added to the GRACE model but did not significantly improve model discrimination. A GRACE model risk score of less than 9 had high sensitivity (96%), thus making it useful for predicting patients with NSTEMI who were at low risk for requiring CABG, which included approximately 21% of patients with NSTEMI. CONCLUSIONS This study could not improve on the GRACE model, which had the best predictive value for identifying a need for CABG after NSTEMI with a broader range of predicted risk levels and high sensitivity, especially in patients with scores lower than 9.
Collapse
Affiliation(s)
- Ali Shafiq
- Cardiovascular Outcomes Research, Saint Luke's Mid America Heart Institute, Kansas City, Missouri; Division of Cardiology, University of Missouri, Kansas City, Missouri.
| | - Jae-Sik Jang
- Division of Cardiology, Inje University Busan Paik Hospital, Busan, Korea
| | - Faraz Kureshi
- Cardiovascular Outcomes Research, Saint Luke's Mid America Heart Institute, Kansas City, Missouri; Division of Cardiology, University of Missouri, Kansas City, Missouri
| | - Timothy J Fendler
- Cardiovascular Outcomes Research, Saint Luke's Mid America Heart Institute, Kansas City, Missouri; Division of Cardiology, University of Missouri, Kansas City, Missouri
| | - Kensey Gosch
- Cardiovascular Outcomes Research, Saint Luke's Mid America Heart Institute, Kansas City, Missouri
| | - Phil G Jones
- Cardiovascular Outcomes Research, Saint Luke's Mid America Heart Institute, Kansas City, Missouri; Division of Cardiology, University of Missouri, Kansas City, Missouri
| | - David J Cohen
- Cardiovascular Outcomes Research, Saint Luke's Mid America Heart Institute, Kansas City, Missouri; Division of Cardiology, University of Missouri, Kansas City, Missouri
| | - Richard Bach
- Division of Cardiology, Washington University School of Medicine, St. Louis, Missouri
| | - John A Spertus
- Cardiovascular Outcomes Research, Saint Luke's Mid America Heart Institute, Kansas City, Missouri; Division of Cardiology, University of Missouri, Kansas City, Missouri
| |
Collapse
|
24
|
Abstract
Clinical practice guidelines endorse the use of palliative care in patients with symptomatic heart failure. Palliative care is conceptualized as supportive care afforded to most patients with chronic, life-limiting illness. However, the optimal content and delivery of palliative care interventions remains unknown and its integration into existing heart failure disease management continues to be a challenge. Therefore, this article comments on the current state of multidisciplinary care for such patients, explores evidence supporting a team-based approach to palliative and end-of-life care for patients with heart failure, and identifies high-priority areas for research.
Collapse
Affiliation(s)
- Timothy J Fendler
- Division of Cardiovascular Outcomes Research, Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City School of Medicine, 4401 Wornall Road, SLNI, CV Research, Suite 5603, Kansas City, MO 64111, USA.
| | - Keith M Swetz
- Section of Palliative Medicine, Division of General Internal Medicine, Department of Medicine, Mayo Clinic, 200 1st St SW, Rochester, MN 55905, USA
| | - Larry A Allen
- Division of Cardiology, Department of Medicine, University of Colorado School of Medicine, 12605 East 16th Avenue, 3rd Floor, Aurora, CO 80045, USA
| |
Collapse
|
25
|
Fendler TJ, Swetz KM, Spertus JA, Austin BA. Abstract 156: Facilitating End-of-Life Decision-Making and Preparedness Planning Among Heart Failure Patients Hospitalized for Advanced Disease. Circ Cardiovasc Qual Outcomes 2016. [DOI: 10.1161/circoutcomes.9.suppl_2.156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
To address the increasingly strident call for better, more informed shared decision-making about treatment decisions and goals of care in patients with end-stage heart failure (HF), we designed and implemented a supportive care intervention for hospitalized patients with a very poor prognosis.
Methods:
All patients admitted to the advanced HF service at a single hospital over a 6-mo. period were screened for inclusion criteria (deemed non-candidacy for LVAD/transplantation and high likelihood for death or persistently poor quality of life at 6 months, based on the Allen risk score). Enrollees were given a written exercise, The Conversation Starter Kit, to complete with their healthcare proxy before an outpatient visit with a HF nurse practitioner (NP) trained in supportive care techniques. The intervention provided at this visit consisted of 5 domains: disease understanding, symptom control, legal matters, goals of care, and the role of the healthcare proxy. The KCCQ, PEACE Illness Acceptance Scale, Decisional Conflict Scale, and Kaldjian’s Goals of Care were collected at enrollment and 1 month after the intervention, along with 6-month outcomes of readmission and death.
Results:
Of 77 patients admitted to the service who were not candidates for advanced therapies, 16 met eligibility criteria. Nine declined participation and 7 of a planned 10 were enrolled; the pilot was terminated early due to low enrollment. Only 2 patients completed the intervention; reasons for not completing varied for the 5 remaining patients. (Table) Despite a pre-existing relationship between patients and NPs, rigorous facilitator training, and a comprehensive, evidence-based, outpatient intervention, significant barriers to implementation included patient reluctance/fear, uncertainty surrounding disease progression, time constraints of completing the intervention within a scheduled clinic visit, and lack of efficacy due to patients having too-advanced disease.
Conclusions:
An intervention to engage very high-risk, advanced HF patients in shared decision-making about end-of-life care failed to be successfully and sustainably implemented. Future work should assess the feasibility and efficacy of designing an early and iterative intervention in a larger population of HF patients with less advanced disease.
Collapse
Affiliation(s)
| | - Keith M Swetz
- Univ of Alabama Cntr for Palliative & Supportive Care, Birmingham, AL
| | | | | |
Collapse
|
26
|
Jang JS, Buchanan DM, Gosch KL, Jones PG, Sharma PK, Shafiq A, Grodzinsky A, Fendler TJ, Graham G, Spertus JA. Association of smoking status with health-related outcomes after percutaneous coronary intervention. Circ Cardiovasc Interv 2016; 8:CIRCINTERVENTIONS.114.002226. [PMID: 25969546 DOI: 10.1161/circinterventions.114.002226] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND Patients who smoke at the time of percutaneous coronary intervention (PCI) would ideally have a strong incentive to quit, but most do not. We sought to compare the health status outcomes of those who did and did not quit smoking after PCI with those who were not smoking before PCI. METHODS AND RESULTS A cohort of 2765 PCI patients from 10 US centers were categorized into never, past (smoked in the past but had quit before PCI), quitters (smoked at time of PCI but then quit), and persistent smokers. Health status was measured with the disease-specific Seattle Angina Questionnaire and the EuroQol 5 dimensions, adjusted for baseline characteristics. In unadjusted analyses, persistent smokers had worse disease-specific and overall health status when compared with other groups. In fully adjusted analyses, persistent smokers showed significantly worse health-related quality of life when compared with never smokers. Importantly, of those who smoked at the time of PCI, quitters had significantly better adjusted Seattle Angina Questionnaire angina frequency scores (mean difference, 2.73; 95% confidence interval, 0.13-5.33) and trends toward higher disease specific (Seattle Angina Questionnaire quality of life mean difference, 1.97; 95% confidence interval, -1.24 to 5.18), and overall (EuroQol 5 dimension visual analog scale scores mean difference, 2.45; 95% confidence interval, -0.58 to 5.49) quality of life when compared with persistent smokers at 12 months. CONCLUSIONS Smokers at the time of PCI have worse health status at 1 year than those who never smoked, whereas smokers who quit after PCI have less angina at 1 year than those who continue smoking.
Collapse
Affiliation(s)
- Jae-Sik Jang
- From the Cardiovascular Outcomes Research, Saint Luke's Mid America Heart Institute, Kansas City, MO (J.-S.J., D.M.B., K.L.G., P.G.J., P.K.S., A.S., A.G., T.J.F., J.A.S.); University of Missouri-Kansas City (J.-S.J., D.M.B., P.K.S., A.S., A.G., T.J.F., J.A.S.); Department of Cardiology, Busan Paik Hospital, University of Inje College of Medicine, Busan, Korea (J.-S.J.); The Aetna Foundation, Hartford, CT (G.G.); and Division of Cardiology, Department of Medicine, University of Connecticut, Farmington (G.G.)
| | - Donna M Buchanan
- From the Cardiovascular Outcomes Research, Saint Luke's Mid America Heart Institute, Kansas City, MO (J.-S.J., D.M.B., K.L.G., P.G.J., P.K.S., A.S., A.G., T.J.F., J.A.S.); University of Missouri-Kansas City (J.-S.J., D.M.B., P.K.S., A.S., A.G., T.J.F., J.A.S.); Department of Cardiology, Busan Paik Hospital, University of Inje College of Medicine, Busan, Korea (J.-S.J.); The Aetna Foundation, Hartford, CT (G.G.); and Division of Cardiology, Department of Medicine, University of Connecticut, Farmington (G.G.)
| | - Kensey L Gosch
- From the Cardiovascular Outcomes Research, Saint Luke's Mid America Heart Institute, Kansas City, MO (J.-S.J., D.M.B., K.L.G., P.G.J., P.K.S., A.S., A.G., T.J.F., J.A.S.); University of Missouri-Kansas City (J.-S.J., D.M.B., P.K.S., A.S., A.G., T.J.F., J.A.S.); Department of Cardiology, Busan Paik Hospital, University of Inje College of Medicine, Busan, Korea (J.-S.J.); The Aetna Foundation, Hartford, CT (G.G.); and Division of Cardiology, Department of Medicine, University of Connecticut, Farmington (G.G.)
| | - Philip G Jones
- From the Cardiovascular Outcomes Research, Saint Luke's Mid America Heart Institute, Kansas City, MO (J.-S.J., D.M.B., K.L.G., P.G.J., P.K.S., A.S., A.G., T.J.F., J.A.S.); University of Missouri-Kansas City (J.-S.J., D.M.B., P.K.S., A.S., A.G., T.J.F., J.A.S.); Department of Cardiology, Busan Paik Hospital, University of Inje College of Medicine, Busan, Korea (J.-S.J.); The Aetna Foundation, Hartford, CT (G.G.); and Division of Cardiology, Department of Medicine, University of Connecticut, Farmington (G.G.)
| | - Praneet K Sharma
- From the Cardiovascular Outcomes Research, Saint Luke's Mid America Heart Institute, Kansas City, MO (J.-S.J., D.M.B., K.L.G., P.G.J., P.K.S., A.S., A.G., T.J.F., J.A.S.); University of Missouri-Kansas City (J.-S.J., D.M.B., P.K.S., A.S., A.G., T.J.F., J.A.S.); Department of Cardiology, Busan Paik Hospital, University of Inje College of Medicine, Busan, Korea (J.-S.J.); The Aetna Foundation, Hartford, CT (G.G.); and Division of Cardiology, Department of Medicine, University of Connecticut, Farmington (G.G.)
| | - Ali Shafiq
- From the Cardiovascular Outcomes Research, Saint Luke's Mid America Heart Institute, Kansas City, MO (J.-S.J., D.M.B., K.L.G., P.G.J., P.K.S., A.S., A.G., T.J.F., J.A.S.); University of Missouri-Kansas City (J.-S.J., D.M.B., P.K.S., A.S., A.G., T.J.F., J.A.S.); Department of Cardiology, Busan Paik Hospital, University of Inje College of Medicine, Busan, Korea (J.-S.J.); The Aetna Foundation, Hartford, CT (G.G.); and Division of Cardiology, Department of Medicine, University of Connecticut, Farmington (G.G.)
| | - Anna Grodzinsky
- From the Cardiovascular Outcomes Research, Saint Luke's Mid America Heart Institute, Kansas City, MO (J.-S.J., D.M.B., K.L.G., P.G.J., P.K.S., A.S., A.G., T.J.F., J.A.S.); University of Missouri-Kansas City (J.-S.J., D.M.B., P.K.S., A.S., A.G., T.J.F., J.A.S.); Department of Cardiology, Busan Paik Hospital, University of Inje College of Medicine, Busan, Korea (J.-S.J.); The Aetna Foundation, Hartford, CT (G.G.); and Division of Cardiology, Department of Medicine, University of Connecticut, Farmington (G.G.)
| | - Timothy J Fendler
- From the Cardiovascular Outcomes Research, Saint Luke's Mid America Heart Institute, Kansas City, MO (J.-S.J., D.M.B., K.L.G., P.G.J., P.K.S., A.S., A.G., T.J.F., J.A.S.); University of Missouri-Kansas City (J.-S.J., D.M.B., P.K.S., A.S., A.G., T.J.F., J.A.S.); Department of Cardiology, Busan Paik Hospital, University of Inje College of Medicine, Busan, Korea (J.-S.J.); The Aetna Foundation, Hartford, CT (G.G.); and Division of Cardiology, Department of Medicine, University of Connecticut, Farmington (G.G.)
| | - Garth Graham
- From the Cardiovascular Outcomes Research, Saint Luke's Mid America Heart Institute, Kansas City, MO (J.-S.J., D.M.B., K.L.G., P.G.J., P.K.S., A.S., A.G., T.J.F., J.A.S.); University of Missouri-Kansas City (J.-S.J., D.M.B., P.K.S., A.S., A.G., T.J.F., J.A.S.); Department of Cardiology, Busan Paik Hospital, University of Inje College of Medicine, Busan, Korea (J.-S.J.); The Aetna Foundation, Hartford, CT (G.G.); and Division of Cardiology, Department of Medicine, University of Connecticut, Farmington (G.G.)
| | - John A Spertus
- From the Cardiovascular Outcomes Research, Saint Luke's Mid America Heart Institute, Kansas City, MO (J.-S.J., D.M.B., K.L.G., P.G.J., P.K.S., A.S., A.G., T.J.F., J.A.S.); University of Missouri-Kansas City (J.-S.J., D.M.B., P.K.S., A.S., A.G., T.J.F., J.A.S.); Department of Cardiology, Busan Paik Hospital, University of Inje College of Medicine, Busan, Korea (J.-S.J.); The Aetna Foundation, Hartford, CT (G.G.); and Division of Cardiology, Department of Medicine, University of Connecticut, Farmington (G.G.).
| |
Collapse
|
27
|
Jang JS, Spertus JA, Arnold SV, Shafiq A, Grodzinsky A, Fendler TJ, Salisbury AC, Tang F, McNulty EJ, Grantham JA, Cohen DJ, Amin AP. Impact of multivessel revascularization on health status outcomes in patients with ST-segment elevation myocardial infarction and multivessel coronary artery disease. J Am Coll Cardiol 2016; 66:2104-2113. [PMID: 26541921 DOI: 10.1016/j.jacc.2015.08.873] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2015] [Revised: 08/21/2015] [Accepted: 08/25/2015] [Indexed: 01/24/2023]
Abstract
BACKGROUND Up to 65% of patients with ST-segment elevation myocardial infarction (STEMI) have multivessel coronary artery disease (MVCAD). Long-term health status of STEMI patients after multivessel revascularization is unknown. OBJECTIVES This study investigated the relationship between multivessel revascularization and health status outcomes (symptoms and quality of life [QoL]) in STEMI patients with MVCAD. METHODS Using a U.S. myocardial infarction registry and the Seattle Angina Questionnaire (SAQ), we determined the health status of patients with STEMI and MVCAD at the time of STEMI and 1 year later. We assessed the association of multivessel revascularization during index hospitalization with 1-year health status using multivariable linear regression analysis, and also examined demographic, clinical, and angiographic factors associated with multivessel revascularization. RESULTS Among 664 STEMI patients with MVCAD, 251 (38%) underwent multivessel revascularization. Most revascularizations were staged during the index hospitalization (64.1%), and 8.0% were staged after discharge, with 27.9% performed during primary percutaneous coronary intervention. Multivessel revascularization was associated with age and more diseased vessels. At 1 year, multivessel revascularization was independently associated with improved symptoms (4.5 points higher SAQ angina frequency score; 95% confidence interval [CI]: 1.0 to 7.9) and QoL (6.6 points higher SAQ QoL score; 95% CI: 2.7 to 10.6). One-year mortality was not different between those who did and did not undergo multivessel revascularization (3.6% vs. 3.4%; log-rank test p = 0.88). CONCLUSIONS Multivessel revascularization improved angina and QoL in STEMI patients with MVCAD. Patient-centered outcomes should be considered in future trials of multivessel revascularization.
Collapse
Affiliation(s)
- Jae-Sik Jang
- Cardiovascular Outcomes Research, Saint Luke's Mid America Heart Institute, Kansas City, Missouri; University of Missouri-Kansas City, Kansas City, Missouri; Department of Cardiology, Busan Paik Hospital, Inje University College of Medicine, Busan, Republic of Korea
| | - John A Spertus
- Cardiovascular Outcomes Research, Saint Luke's Mid America Heart Institute, Kansas City, Missouri; University of Missouri-Kansas City, Kansas City, Missouri.
| | - Suzanne V Arnold
- Cardiovascular Outcomes Research, Saint Luke's Mid America Heart Institute, Kansas City, Missouri; University of Missouri-Kansas City, Kansas City, Missouri
| | - Ali Shafiq
- Cardiovascular Outcomes Research, Saint Luke's Mid America Heart Institute, Kansas City, Missouri; University of Missouri-Kansas City, Kansas City, Missouri
| | - Anna Grodzinsky
- Cardiovascular Outcomes Research, Saint Luke's Mid America Heart Institute, Kansas City, Missouri; University of Missouri-Kansas City, Kansas City, Missouri
| | - Timothy J Fendler
- Cardiovascular Outcomes Research, Saint Luke's Mid America Heart Institute, Kansas City, Missouri; University of Missouri-Kansas City, Kansas City, Missouri
| | - Adam C Salisbury
- Cardiovascular Outcomes Research, Saint Luke's Mid America Heart Institute, Kansas City, Missouri; University of Missouri-Kansas City, Kansas City, Missouri
| | - Fengming Tang
- Cardiovascular Outcomes Research, Saint Luke's Mid America Heart Institute, Kansas City, Missouri
| | - Edward J McNulty
- Division of Cardiology, Kaiser Permanente Medical Center, San Francisco, California
| | - J Aaron Grantham
- Cardiovascular Outcomes Research, Saint Luke's Mid America Heart Institute, Kansas City, Missouri; University of Missouri-Kansas City, Kansas City, Missouri
| | - David J Cohen
- Cardiovascular Outcomes Research, Saint Luke's Mid America Heart Institute, Kansas City, Missouri; University of Missouri-Kansas City, Kansas City, Missouri
| | - Amit P Amin
- Cardiovascular Division, Washington University School of Medicine, St. Louis, Missouri; Barnes-Jewish Hospital, St. Louis, Missouri
| |
Collapse
|
28
|
Khazanie P, Hammill BG, Patel CB, Kiernan MS, Cooper LB, Arnold SV, Fendler TJ, Spertus JA, Curtis LH, Hernandez AF. Use of Heart Failure Medical Therapies Among Patients With Left Ventricular Assist Devices: Insights From INTERMACS. J Card Fail 2016; 22:672-9. [PMID: 26892975 DOI: 10.1016/j.cardfail.2016.02.004] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Revised: 02/04/2016] [Accepted: 02/10/2016] [Indexed: 11/19/2022]
Abstract
BACKGROUND Use of left ventricular assist devices (LVADs) for treatment of advanced heart failure has expanded significantly over the past decade. However, concomitant use of heart failure medical therapies after implant is poorly characterized. METHODS AND RESULTS We examined the use of heart failure medications before and after LVAD implant in adult patients enrolled in the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) between 2008 and 2013 (N = 9359). Using logistic regression, we examined relationships between patient characteristics and medication use at 3 months after implant. Baseline rates of heart failure therapies before implant were 38% for angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs), 55% for β-blockers, 40% for mineralocorticoid receptor antagonists (MRAs), 87% for loop diuretics, 54% for amiodarone, 11% for phosphodiesterase inhibitors, 22% for warfarin, and 54% for antiplatelet agents. By 3 months after implant, the rates were 50% for ACE inhibitors or ARBs, 68% for β-blockers, 33% for MRAs, 68% for loop diuretics, 42% for amiodarone, 21% for phosphodiesterase inhibitors, 92% for warfarin, and 84% for antiplatelet agents. In general, age, preimplant INTERMACS profile, and prior medication use were associated with medication use at 3 months. CONCLUSIONS Overall use of neurohormonal antagonists was low after LVAD implant, whereas use of loop diuretics and amiodarone remained high. Heart failure medication use is highly variable, but appears to generally increase after LVAD implantation. Low neurohormonal antagonist use may reflect practice uncertainty in the clinical utility of these medications post-LVAD.
Collapse
Affiliation(s)
- Prateeti Khazanie
- Division of Cardiology and the Colorado Cardiovascular Outcomes Consortium, University of Colorado School of Medicine, Aurora, CO
| | - Bradley G Hammill
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Chetan B Patel
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina; Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | | | - Lauren B Cooper
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina; Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | | | | | - John A Spertus
- Saint Luke's Mid America Heart Institute, Kansas City, Missouri
| | - Lesley H Curtis
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina; Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Adrian F Hernandez
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina; Department of Medicine, Duke University School of Medicine, Durham, North Carolina.
| |
Collapse
|
29
|
Fendler TJ, Spertus JA, Kennedy KF, Chen LM, Perman SM, Chan PS. Alignment of Do-Not-Resuscitate Status With Patients' Likelihood of Favorable Neurological Survival After In-Hospital Cardiac Arrest. JAMA 2015; 314:1264-71. [PMID: 26393849 PMCID: PMC4701196 DOI: 10.1001/jama.2015.11069] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE After patients survive an in-hospital cardiac arrest, discussions should occur about prognosis and preferences for future resuscitative efforts. OBJECTIVE To assess whether patients' decisions for do-not-resuscitate (DNR) orders after a successful resuscitation from in-hospital cardiac arrest are aligned with their expected prognosis. DESIGN, SETTING, AND PARTICIPANTS Within Get With The Guidelines-Resuscitation, we identified 26,327 patients with return of spontaneous circulation (ROSC) after in-hospital cardiac arrest between April 2006 and September 2012 at 406 US hospitals. Using a previously validated prognostic tool, each patient's likelihood of favorable neurological survival (ie, without severe neurological disability) was calculated. The proportion of patients with DNR orders within each prognosis score decile and the association between DNR status and actual favorable neurological survival were examined. EXPOSURES Do-not-resuscitate orders within 12 hours of ROSC. MAIN OUTCOMES AND MEASURES Likelihood of favorable neurological survival. RESULTS Overall, 5944 (22.6% [95% CI, 22.1%-23.1%]) patients had DNR orders within 12 hours of ROSC. This group was older and had higher rates of comorbidities (all P < .05) than patients without DNR orders. Among patients with the best prognosis (decile 1), 7.1% (95% CI, 6.1%-8.1%) had DNR orders even though their predicted rate of favorable neurological survival was 64.7% (95% CI, 62.8%-66.6%). Among patients with the worst expected prognosis (decile 10), 36.0% (95% CI, 34.2%-37.8%) had DNR orders even though their predicted rate for favorable neurological survival was 4.0% (95% CI, 3.3%-4.7%) (P for both trends <.001). This pattern was similar when DNR orders were redefined as within 24 hours, 72 hours, and 5 days of ROSC. The actual rate of favorable neurological survival was higher for patients without DNR orders (30.5% [95% CI, 29.9%-31.1%]) than it was for those with DNR orders (1.8% [95% CI, 1.6%-2.0%]). This pattern of lower survival among patients with DNR orders was seen in every decile of expected prognosis. CONCLUSIONS AND RELEVANCE Although DNR orders after in-hospital cardiac arrest were generally aligned with patients' likelihood of favorable neurological survival, only one-third of patients with the worst prognosis had DNR orders. Patients with DNR orders had lower survival than those without DNR orders, including those with the best prognosis.
Collapse
Affiliation(s)
- Timothy J. Fendler
- Department of Cardiology, Saint Luke's Mid America Heart Institute, Kansas City, MO
| | - John A. Spertus
- Department of Cardiology, Saint Luke's Mid America Heart Institute, Kansas City, MO
| | - Kevin F. Kennedy
- Department of Cardiology, Saint Luke's Mid America Heart Institute, Kansas City, MO
| | - Lena M. Chen
- Department of Medicine, University of Michigan, Ann Arbor, MI
| | - Sarah M. Perman
- Department of Emergency Medicine, University of Colorado School of Medicine, Denver, CO
| | - Paul S. Chan
- Department of Cardiology, Saint Luke's Mid America Heart Institute, Kansas City, MO
| |
Collapse
|
30
|
Fendler TJ, Spertus JA, Gosch K, Jones PG, Bruce JM, Nassif ME, Flint KM, Dunlay SM, Allen LA, Arnold SV. Abstract 1: Incidence and Predictors of Cognitive Decline in Patients with Left Ventricular Assist Devices. Circ Cardiovasc Qual Outcomes 2015. [DOI: 10.1161/circoutcomes.8.suppl_2.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
After left ventricular assist device (LVAD) for end-stage heart failure, cognitive function should improve due to increased cerebral perfusion. However, stroke (a well-known LVAD complication) and even subclinical cerebral ischemia may also occur and manifest as transient or permanent cognitive decline. We sought to describe the incidence and predictors of cognitive decline after LVAD using a valid, sensitive assessment tool.
Methods:
As part of the INTERMACS registry, cognitive function was assessed before LVAD and at each follow-up with the Trailmaking B Test (TBT), where a subject is timed connecting 25 dots labeled with alternating, consecutive numbers and letters (1, A, 2, B, etc.). The TBT can detect several forms of cognitive impairment, including subclinical stroke. Longer times are worse, and cognitive decline was defined as a clinically important increase from baseline to highest follow-up score using Cohen’s D Effect Size (0.2*baseline SD = 13 s). Patients who completed baseline and at least 1 follow-up TBT were included. Multivariable logistic regression was used to examine the association between patient characteristics and cognitive decline after LVAD.
Results:
Among 1151 LVAD patients, median age was 60-69, 19% were female, and 40% were INTERMACS profile 1-2 (cardiogenic shock or declining despite inotropes) at implant. Among patients with 12-mo follow-up, mean TBT score improved from 126 at baseline to 123 at 1 yr. In the total cohort, 333 (29%) patients had significant cognitive decline within 12 mo of LVAD placement. Increasing age, chronic renal disease, better baseline TBT score (shorter time), and higher INTERMACS profiles (≥ 3; less severe heart failure) were significantly associated with greater odds of cognitive decline (Figure).
Conclusion:
In a large LVAD registry, cognitive decline occurred in over a quarter of patients in the year after LVAD and was associated with older age, renal disease, higher baseline cognitive function, and more stable heart failure at implant. These results define the frequency of an important adverse event and provide new insights regarding outcomes after LVAD. Future studies are needed to explore the association of transient and permanent cognitive decline with subsequent stroke, health status, and mortality in patients after LVAD placement.
Collapse
Affiliation(s)
| | | | - Kensey Gosch
- St. Luke’s Mid America Heart Institute, Kansas City, MO
| | | | | | | | | | | | | | | |
Collapse
|
31
|
Fendler TJ, Nassif ME, Kennedy KF, Spertus JA, LaRue SJ, Vader JM, Silvestry SC, Joseph SM, Arnold SV. Abstract 225: Frequency and Assessment of Poor Global Outcome in Patients with Left Ventricular Assist Devices. Circ Cardiovasc Qual Outcomes 2015. [DOI: 10.1161/circoutcomes.8.suppl_2.225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Left ventricular assist device (LVAD) therapy can improve survival and quality of life in advanced heart failure (HF), but some patients may still do poorly after LVAD. Understanding the likelihood of experiencing poorer outcomes after LVAD can better inform patients and calibrate their expectations.
Methods:
We analyzed patients receiving LVAD therapy from January 2012 to October 2013 at a single, high-volume, high-acuity center. We defined a poor global outcome at 1 year after LVAD as the occurrence of death, disabling stroke (precluding transplant), poor patient-reported health status (most recent KCCQ at 3, 6, or 12 months < 45, corresponding to NYHA class IV), or recurrent HF (≥2 HF readmissions post-implant). We compared characteristics of those with and without poor global outcome.
Results:
Among 164 LVAD recipients who had 1-year outcomes data, mean age was 56, 76.7% were white, 20.9% were female, and 85.9% were INTERMACS Profile 1 or 2 (cardiogenic shock or declining despite inotropes). Poor global outcome occurred in 58 (35.4%) patients at 1 year, of whom 37 (63.8%) died, 17 (29.3%) had a most recent KCCQ score < 45, 3 (5.2%) had ≥2 HF readmissions, and 1 (1.7%) had a disabling stroke (Figure). Eight of the patients who died also experienced one of the three other poor outcomes prior to death. Patients who experienced a poor global outcome were more likely to be designated for destination therapy (46.4% vs. 23.6%, p=0.01) than bridge to transplant, have longer index admissions (median [IQR]: 39 [24, 57] days vs. 25 [18, 35] days, p=0.003), and have major GI bleeding (44.2% vs. 27.7%, p=0.056), and were less likely to undergo LVAD exchange (0% vs. 12.3%, p=0.004).
Conclusion:
In this large, single-center study assessing global outcome after LVAD implantation, we found that about a third of all patients had experienced a poor global outcome at 1 year. While LVAD therapy remains life-saving and the standard of care for many patients with advanced heart failure, these findings could help guide discussions with eligible patients and families. Future work should compare patients’ pre-LVAD expectations with likely outcomes and create risk models to estimate the probability of poorer outcomes for individual patients using pre-procedural factors.
Collapse
|
32
|
Fendler TJ, Spertus JA, Gosch KL, Jones PG, Bruce JM, Nassif ME, Flint KM, Dunlay SM, Allen LA, Arnold SV. Incidence and predictors of cognitive decline in patients with left ventricular assist devices. Circ Cardiovasc Qual Outcomes 2015; 8:285-91. [PMID: 25925372 DOI: 10.1161/circoutcomes.115.001856] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Accepted: 03/31/2015] [Indexed: 02/04/2023]
Abstract
BACKGROUND After left ventricular assist device (LVAD) placement for advanced heart failure, increased cerebral perfusion should result in improved cognitive function. However, stroke (a well-known LVAD complication) and subclinical cerebral ischemia may result in transient or permanent cognitive decline. We sought to describe the incidence and predictors of cognitive decline after LVAD using a valid, sensitive assessment tool. METHODS AND RESULTS Among 4419 patients in the Interagency Registry for Mechanically Assisted Circulatory Support who underwent LVAD implantation between May 2012 and December 2013, cognitive function was assessed in 1173 patients with the Trail Making B Test before LVAD and at 3, 6, and 12 months. The test detects several forms of cognitive impairment, including subclinical stroke. Cognitive decline was defined as a clinically important increase during follow-up using a moderate Cohen d effect size of 0.5×baseline SD (32 s). The cumulative incidence of cognitive decline in the year after LVAD implantation, treating death and transplantation as competing risks, was 29.2%. In adjusted analysis, older age (≥70 versus <50 years; hazard ratio, 2.24; 95% confidence interval 1.46-3.44; P(trend)<0.001) and destination therapy (hazard ratio, 1.42; 95% confidence interval, 1.05-1.92) were significantly associated with greater risk of cognitive decline. CONCLUSIONS Cognitive decline occurs commonly in patients in the year after LVAD and is associated with older age and destination therapy. These results could have important implications for patient selection and improved communication of risks before LVAD implantation. Additional studies are needed to explore the association between cognitive decline and subsequent stroke, health status, and mortality in patients after LVAD.
Collapse
Affiliation(s)
- Timothy J Fendler
- From the Mid-America Heart Institute, Kansas City, MO (T.J.F., J.A.S., K.L.G., P.G.J., S.V.A.); University of Missouri-Kansas City (T.J.F., J.A.S., J.M.B., S.V.A.); Washington University School of Medicine, Saint Louis, MO (M.E.N.); University of Colorado School of Medicine, Aurora (K.M.F., L.A.A.); and Mayo Clinic of Rochester, MN (S.M.D.).
| | - John A Spertus
- From the Mid-America Heart Institute, Kansas City, MO (T.J.F., J.A.S., K.L.G., P.G.J., S.V.A.); University of Missouri-Kansas City (T.J.F., J.A.S., J.M.B., S.V.A.); Washington University School of Medicine, Saint Louis, MO (M.E.N.); University of Colorado School of Medicine, Aurora (K.M.F., L.A.A.); and Mayo Clinic of Rochester, MN (S.M.D.)
| | - Kensey L Gosch
- From the Mid-America Heart Institute, Kansas City, MO (T.J.F., J.A.S., K.L.G., P.G.J., S.V.A.); University of Missouri-Kansas City (T.J.F., J.A.S., J.M.B., S.V.A.); Washington University School of Medicine, Saint Louis, MO (M.E.N.); University of Colorado School of Medicine, Aurora (K.M.F., L.A.A.); and Mayo Clinic of Rochester, MN (S.M.D.)
| | - Philip G Jones
- From the Mid-America Heart Institute, Kansas City, MO (T.J.F., J.A.S., K.L.G., P.G.J., S.V.A.); University of Missouri-Kansas City (T.J.F., J.A.S., J.M.B., S.V.A.); Washington University School of Medicine, Saint Louis, MO (M.E.N.); University of Colorado School of Medicine, Aurora (K.M.F., L.A.A.); and Mayo Clinic of Rochester, MN (S.M.D.)
| | - Jared M Bruce
- From the Mid-America Heart Institute, Kansas City, MO (T.J.F., J.A.S., K.L.G., P.G.J., S.V.A.); University of Missouri-Kansas City (T.J.F., J.A.S., J.M.B., S.V.A.); Washington University School of Medicine, Saint Louis, MO (M.E.N.); University of Colorado School of Medicine, Aurora (K.M.F., L.A.A.); and Mayo Clinic of Rochester, MN (S.M.D.)
| | - Michael E Nassif
- From the Mid-America Heart Institute, Kansas City, MO (T.J.F., J.A.S., K.L.G., P.G.J., S.V.A.); University of Missouri-Kansas City (T.J.F., J.A.S., J.M.B., S.V.A.); Washington University School of Medicine, Saint Louis, MO (M.E.N.); University of Colorado School of Medicine, Aurora (K.M.F., L.A.A.); and Mayo Clinic of Rochester, MN (S.M.D.)
| | - Kelsey M Flint
- From the Mid-America Heart Institute, Kansas City, MO (T.J.F., J.A.S., K.L.G., P.G.J., S.V.A.); University of Missouri-Kansas City (T.J.F., J.A.S., J.M.B., S.V.A.); Washington University School of Medicine, Saint Louis, MO (M.E.N.); University of Colorado School of Medicine, Aurora (K.M.F., L.A.A.); and Mayo Clinic of Rochester, MN (S.M.D.)
| | - Shannon M Dunlay
- From the Mid-America Heart Institute, Kansas City, MO (T.J.F., J.A.S., K.L.G., P.G.J., S.V.A.); University of Missouri-Kansas City (T.J.F., J.A.S., J.M.B., S.V.A.); Washington University School of Medicine, Saint Louis, MO (M.E.N.); University of Colorado School of Medicine, Aurora (K.M.F., L.A.A.); and Mayo Clinic of Rochester, MN (S.M.D.)
| | - Larry A Allen
- From the Mid-America Heart Institute, Kansas City, MO (T.J.F., J.A.S., K.L.G., P.G.J., S.V.A.); University of Missouri-Kansas City (T.J.F., J.A.S., J.M.B., S.V.A.); Washington University School of Medicine, Saint Louis, MO (M.E.N.); University of Colorado School of Medicine, Aurora (K.M.F., L.A.A.); and Mayo Clinic of Rochester, MN (S.M.D.)
| | - Suzanne V Arnold
- From the Mid-America Heart Institute, Kansas City, MO (T.J.F., J.A.S., K.L.G., P.G.J., S.V.A.); University of Missouri-Kansas City (T.J.F., J.A.S., J.M.B., S.V.A.); Washington University School of Medicine, Saint Louis, MO (M.E.N.); University of Colorado School of Medicine, Aurora (K.M.F., L.A.A.); and Mayo Clinic of Rochester, MN (S.M.D.)
| |
Collapse
|
33
|
Fendler TJ, Jones P, Ting H, Kureshi F, Salisbury A, Sharma P, Chhatriwalla A, Spertus J. PROVIDER VARIABILITY AND CHARACTERISTICS ASSOCIATED WITH BIVALIRUDIN USE FOR BLEEDING AVOIDANCE IN PERCUTANEOUS CORONARY INTERVENTION AFTER IMPLEMENTATION OF A DECISION SUPPORT TOOL. J Am Coll Cardiol 2014. [DOI: 10.1016/s0735-1097(14)60210-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
|
34
|
Raymer DS, Fendler TJ, Nassif ME, Novak E, Ewald GA, LaRue SJ. Poor Glycemic Control Is Associated with Worse Outcomes in Patients with Type II Diabetes Who Undergo Left Ventricular Assist Device Implantation. J Card Fail 2013. [DOI: 10.1016/j.cardfail.2013.06.197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|