Irina Sobol

Characteristics of Hospitalizations for Heart Failure with Preserved Ejection Fraction

BACKGROUND Hospitalizations for heart failure with preserved ejection fraction (HFpEF) are increasing. There are limited data examining national trends in patients hospitalized with HFpEF. METHODS Using the Nationwide Inpatient Sample, we examined 5,046,879 hospitalizations with a diagnosis of acute heart failure in 2003-2012, stratifying hospitalizations by HFpEF and heart failure with reduced ejection fraction (HFrEF). Patient and hospital characteristics, in-hospital mortality, and length of stay were examined. RESULTS Compared with HFrEF, those with HFpEF were older, more commonly female, and more likely to have hypertension, atrial fibrillation, chronic lung disease, chronic renal failure, and anemia. Over time, HFpEF comprised increasing proportions of men and patients aged ≥75 years. In-hospital mortality rate for HFpEF decreased by 13%, largely due to improved survival in those aged ≥65 years. Multivariable regression analyses showed that pulmonary circulation disorders, liver disease, and chronic renal failure were independent predictors of in-hospital mortality, whereas treatable diseases including hypertension, coronary artery disease, and diabetes were inversely associated. CONCLUSIONS This study represents the largest cohort of patients hospitalized with HFpEF to date, yielding the following observations: number of hospitalizations for HFpEF was comparable with that of HFrEF; patients with HFpEF were most often women and elderly, with a high burden of comorbidities; outcomes appeared improved among a subset of patients; pulmonary hypertension, liver disease, and chronic renal failure were strongly associated with poor outcomes.

Sex‐ and Race‐Related Differences in Characteristics and Outcomes of Hospitalizations for Heart Failure With Preserved Ejection Fraction

Background Sex and race have emerged as important contributors to the phenotypic heterogeneity of heart failure with preserved ejection fraction (HFpEF). However, there remains a need to identify important sex‐ and race‐related differences in characteristics and outcomes using a nationally representative cohort. Methods and Results Data were obtained from the Agency for Healthcare Research and Quality Healthcare Cost and Utilization Project—Nationwide Inpatient Sample files between 2008 and 2012. Hospitalizations with a diagnosis of HFpEF were included for analysis. Demographics, hospital characteristics, and age‐adjusted comorbidity prevalence rates were compared between men and women and whites and blacks. In‐hospital mortality was determined and compared for each subgroup. Multivariable regression analyses were used to identify and compare correlates of in‐hospital mortality for each subgroup. A sample of 1 889 608 hospitalizations was analyzed. Men with HFpEF were slightly younger than women with HFpEF and had a higher Elixhauser comorbidity score. Men experienced higher in‐hospital mortality compared with women, a finding that was attenuated after adjusting for comorbidity. Blacks with HFpEF were younger than whites with HFpEF, with lower rates of most comorbidities. Hypertension, diabetes, anemia, and chronic renal failure were more common among blacks. Blacks experienced lower in‐hospital mortality compared with whites, even after adjusting for age and comorbidity. Important correlates of mortality among all 4 subgroups included pulmonary circulation disorders, liver disease, and chronic renal failure. Atrial fibrillation was an important correlate of mortality only among women and blacks. Conclusions Differences in patient characteristics and outcomes reinforce the notion that sex and race contribute to the phenotypic heterogeneity of HFpEF.

Pulmonary hypertension complicating multiple myeloma.

Pulmonary hypertension (PH) is an infrequently reported complication of multiple myeloma (MM). PH has been more commonly associated with amyloidosis, myeloproliferative diseases, and the POEMS (polyneuropathy, organomegaly, endocrinopathy, monoclonal protein, skin changes) syndrome. PH in MM is typically mild to moderate and may be secondary to a variety of conditions, which include left ventricular dysfunction, high-output cardiac failure, chronic kidney disease, treatment-related toxicities, and precapillary involvement. We describe 3 patients with MM and severe PH. Each patient underwent right heart catheterization. All patients demonstrated elevated pulmonary pressures, transpulmonary gradients, and pulmonary vascular resistance. Each patient was ultimately treated with pulmonary vasodilator therapy with improvement in cardiopulmonary symptoms. Additional studies are needed to define the prevalence, prognosis, and pathogenesis of PH in this complex population and to help clarify who may benefit from targeted PH therapy.

CHARACTERIZATION AND IMPACT OF COMORBIDITY AMONG GENDER AND RACIAL SUBGROUPS HOSPITALIZED WITH HEART FAILURE WITH PRESERVED EJECTION FRACTION

Heart failure with preserved ejection fraction (HFpEF) is challenging to treat in part due to its phenotypic heterogeneity. There are limited data on differences in characteristics and outcomes of gender and race subgroups. Using the Nationwide Inpatient Sample, we examined 2,102,780

Rapidly Progressive Cardiac Failure Due to Giant Cell Myocarditis

A 56-year-old Hispanic female from the Dominican Republic with no history of cardiac disease presented to an outside hospital in November 2012 with fever, abdominal pain, nausea, and vomiting. One year prior to admission, the patient developed frequent flu-like symptoms with subjective fever, chills, diaphoresis, and myalgias. These symptoms would last about 1 week and resolve spontaneously. The patient’s daughter described at least six such episodes in the past year. She denied any exertional dyspnea, palpitations, chest pain, exercise intolerance, orthopnea, paroxysmal nocturnal dyspnea, or lower extremity edema. In October 2012, the patient visited the Dominican Republic. There she was admitted to a local hospital for swelling of the face and neck and generalized body rash that, per the patient’s daughter, Bresembled hives.^ She denied any breathing, speech, or swallowing difficulties. The patient was treated with prednisone and hydroxyzine (doses unknown). By the time of discharge, the swelling had resolved and the rash was improving except for desquamation and light brown macular lesions on the palms. Two weeks following that admission and 2 days prior to her flight back to the United States of America (USA), the patient started to complain of nausea, vomiting, abdominal pain, subjective fever, chills, and myalgias. She also complained of chest discomfort. Upon arrival in the USA, she presented to an outside hospital for evaluation on November 19th 2012. On physical examination, she was tachycardic with a heart rate of 120 bpm and hypotensive with a blood pressure of 95/40 mmHg. Laboratory analysis revealed an elevated troponin of 4.6 ng/mL. An electrocardiogram (EKG) showed sinus tachycardia at 126 bpm and a normal axis. The QTc was prolonged at 427 ms. There were sub-millimeter P-R depressions but no S-T elevations or depressions. There was a Q wave in V1 and V2 with low voltage. Given the elevated troponin, there was concern for a non-ST elevation myocardial infarction and the patient was transferred to our institution for cardiac catheterization. The patient’s past medical history was notable for hypertension, hyperlipidemia, diabetes mellitus type 2, and chronic renal insufficiency with a baseline creatinine of 1.3 mg/dL. Patient had an allergy to shellfish. She denied the use of tobacco, alcohol, or illicit drugs. Family history was notable for hypertension and diabetes in many relatives, but there was no family history of sudden death, autoimmune, or connective tissue disease. The patient’s physical examination was significant for an elevated jugular venous pressure, distant heart sounds, and crackles in the lung bases. On examination of the skin, hyperpigmented macules and scaly plaques on hands with mild desquamation were found. HSSJ (2015) 11:182–186 DOI 10.1007/s11420-015-9449-5 HSS Journal ® The Musculoskeletal Journal of Hospital for Special Surgery

ASSESSMENT OF UNEXPLAINED CARDIOMYOPATHY: CLINICAL UTILITY OF DELAYED-ENHANCEMENT CARDIAC MAGNETIC RESONANCE COMPARED TO ENDOMYOCARDIAL BIOPSY

Results: 43 patients were studied (60% male, 48±18yo, LVEF 38±21%), comprising 35% of all patients who underwent EMB between 1/0711/2011. Mean interval between EMB and CMR was 15±20 days; 60% underwent both within 7 days. CMR was positive for myocardial scar in 31 patients (87% focal, 13% diffuse). EMB was diagnostic in 12 patients (amyloid=5, myocarditis=4, sarcoid=2, lymphoma=1). CMR yielded high sensitivity (92%) and negative predictive value (93%). Only one patient with negative CMR had positive EMB it showed vascular amyloid without myocardial abnormalities. Over half (18/29) of patients with scar on CMR had negative EMB (specificity =42%, positive predictive value=38%).