Judith Z. Goldfinger

Palliative Care in the Treatment of Advanced Heart Failure

Heart failure is epidemic in developed countries and is expanding rapidly worldwide. Roughly 5% of patients with heart failure have end-stage disease that is refractory to medical therapy (stage D heart failure).1 Palliative care consultation relieves symptoms, improves patient satisfaction, and decreases the costs of care for these patients. Despite this, only a small fraction of end-stage heart failure patients receive palliative care consultation. In recognition of this, palliative/hospice care referral was recommended for end-stage heart failure (Level of Evidence 1A) in the most recent American College of Cardiology/American Heart Association heart failure guidelines.2 To identify evidence-based studies of palliative care in heart failure, we searched the Medline database for literature with the medical subject headings “heart failure” and “palliative care,” “supportive care,” or “symptom management” and found 394 results. We identified 92 systematic reviews, 44 of which were English-language systematic reviews published within the past 5 years. More than 5 million Americans have heart failure, with a yearly incidence estimated to be >500 000.3 The number of deaths due to heart failure in 2004 was 284 365, which exceeds the deaths due to lung cancer, breast cancer, prostate cancer, and HIV/AIDS combined (Table 1).3–5 Even as the national death rate decreased by 2% from 1994 to 2004, deaths due to heart failure increased by 28%. View this table: Table 1. Incidence of and Number of Deaths Due to Heart Failure Compared With Other Common Causes of Death in the United States The yearly cost of heart failure was roughly

Thoracic Aortic Aneurysm and Dissection

30 billion in 2006.6 The mean hospital length of stay is almost 6 days, and more than one third of patients are admitted for more than 5 days. Nearly half of the hospitalizations for heart failure exceed Medicare diagnosis-related groups reimbursement.7 Compared with all other patients, …

Project HEAL: Peer Education Leads to Weight Loss in Harlem

Aortic dissection is the most devastating complication of thoracic aortic disease. In the more than 250 years since thoracic aortic dissection was first described, much has been learned about diseases of the thoracic aorta. In this review, we describe normal thoracic aortic size; risk factors for dissection, including genetic and inflammatory conditions; the underpinnings of genetic diseases associated with aneurysm and dissection, including Marfan syndrome and the role of transforming growth factor beta signaling; data on the role for medical therapies in aneurysmal disease, including beta-blockers, angiotensin receptor blockers, and angiotensin-converting enzyme inhibitors; prophylactic surgery for aneurysm; surgical techniques for the aortic root; and surgical and endovascular management of aneurysm and dissection for different aortic segments.

Peer education for secondary stroke prevention in inner-city minorities: Design and methods of the prevent recurrence of all inner-city strokes through education randomized controlled trial

Background. Obesity and diabetes are epidemic in the predominantly minority Harlem community. To address them, a coalition of community and academic leaders tested the effectiveness of a peer-led weight loss course. Methods. The coalition developed Project HEAL: Healthy Eating, Active Lifestyles through extensive collaboration with community members and experts in nutrition, exercise, and peer education. We piloted the course in a local church and assessed its impact through pre and post course weights, self-reported behaviors and quality of life. Results. Twenty-six overweight and obese African American adults lost a mean of 4.4 pounds at 10 weeks, 8.4 pounds at 22 weeks, and 9.8 pounds at 1 year. Participants reported decreased fat consumption and sedentary hours, and improved health related quality of life. Conclusions. A peer-led, community-based course can lead to weight loss and behavior change. The minority communities most affected by obesity and diabetes may benefit from this low-cost, culturally appropriate intervention.

Concerns about medications mediate the association of posttraumatic stress disorder with adherence to medication in stroke survivors

BACKGROUND The highest risk for stroke is among survivors of strokes or transient ischemic attacks (TIA). However, use of proven-effective cardiovascular medications to control stroke risk is suboptimal, particularly among the Black and Latino populations disproportionately impacted by stroke. METHODS A partnership of Harlem and Bronx community representatives, stroke survivors, researchers, clinicians, outreach workers and patient educators used community-based participatory research to conceive and develop the Prevent Recurrence of All Inner-city Strokes through Education (PRAISE) trial. Using data from focus groups with stroke survivors, they tailored a peer-led, community-based chronic disease self-management program to address stroke risk factors. PRAISE will test, in a randomized controlled trial, whether this stroke education intervention improves blood pressure control and a composite outcome of blood pressure control, lipid control, and use of antithrombotic medications. RESULTS Of the 582 survivors of stroke and TIA enrolled thus far, 81% are Black or Latino and 56% have an annual income less than

Effect of Peer Education on Stroke Prevention: The Prevent Recurrence of All Inner-City Strokes Through Education Randomized Controlled Trial

15,000. Many (33%) do not have blood pressures in the target range, and most (66%) do not have control of all three major stroke risk factors. CONCLUSIONS Rates of stroke recurrence risk factors remain suboptimal in the high risk, urban, predominantly minority communities studied. With a community-partnered approach, PRAISE has recruited a large number of stroke and TIA survivors to date, and may prove successful in engaging those at highest risk for stroke and reducing disparities in stroke outcomes in inner-city communities.

End-of-Life Options for Patients with Advanced Heart Failure

OBJECTIVES Post-traumatic stress disorder (PTSD) can be a consequence of acute medical events and has been associated with non-adherence to medications. We tested whether increased concerns about medications could explain the association between PTSD and non-adherence to medication in stroke survivors. DESIGN We surveyed 535 participants aged 40 years or older who had at least one stroke or transient ischaemic attack in the previous 5 years. METHODS We assessed PTSD using the PTSD checklist-specific for stroke, medication adherence with the Morisky Medication Adherence Questionnaire, and beliefs about medications with the Beliefs about Medicines Questionnaire. We used logistic regression to test whether concerns about medications mediated the association between stroke-induced PTSD and non-adherence to medication. Covariates for adjusted analyses included age, sex, race, comorbid medical conditions, stroke-related disability, years since last stroke/TIA, and depression. RESULTS Symptoms of PTSD were correlated with greater concerns about medications (r = 0.45; p < .001), and both were associated with medication non-adherence. Adjustment for concerns about medications attenuated the relationship between PTSD and non-adherence to medication, from an odds ratio [OR] of 1.04 (95% confidence interval [CI], 1.01-1.06; OR, 1.63 per 1 SD) to an OR of 1.02 (95% CI, 1.00-1.05; OR, 1.32 per 1 SD), and increased concerns about medications remained associated with increased odds of non-adherence to medication (OR, 1.17; 95% CI, 1.10-1.25; OR, 1.72 per 1 SD) in this fully adjusted model. A bootstrap mediation test suggested that the indirect effect was statistically significant and explained 38% of the association of PTSD to medication non-adherence, and the direct effect of PTSD symptoms on medication non-adherence was no longer significant. CONCLUSION Increased concerns about medications explain a significant proportion of the association between PTSD symptoms and non-adherence to medication in stroke survivors.

Brain-Heart Interaction in Takotsubo Cardiomyopathy

Background and Purpose— Efforts to reduce disparities in recurrent stroke among Black and Latino stroke survivors have met with limited success. We aimed to determine the effect of peer education on secondary stroke prevention among predominantly minority stroke survivors. Methods— Between 2009 and 2012, we enrolled 600 stroke or transient ischemic attack survivors from diverse, low-income communities in New York City into a 2-arm randomized clinical trial that compared a 6 week (1 session/week), peer-led, community-based, stroke prevention self-management group workshop (N=301) to a wait-list control group (N=299). The primary outcome was the proportion with a composite of controlled blood pressure (<140/90 mm Hg), low-density lipoprotein cholesterol <100 mg/dL, and use of antithrombotic medications at 6 months. Secondary outcomes included control of the individual stroke risk factors. All analyses were by intent-to-treat. Results— There was no difference in the proportion of intervention and control group participants achieving the composite outcome (34% versus 34%; P=0.98). The proportion with controlled blood pressure at 6 months was greater in the intervention group than in the control group (76% versus 67%; P=0.02). This corresponded to a greater change in systolic blood pressure in the intervention versus control group (−3.63 SD, 19.81 mm Hg versus +0.34 SD, 23.76 mm Hg; P=0.04). There were no group differences in the control of cholesterol or use of antithrombotics. Conclusions— A low-cost peer education self-management workshop modestly improved blood pressure, but not low-density lipoprotein cholesterol or antithrombotic use, among stroke and transient ischemic attack survivors from vulnerable, predominantly minority urban communities. Clinical Trial Registration— URL: http://www.clinicaltrials.gov/show/NCT0102727. Unique identifier: NCT01027273.

Myocardial Recovery and the Failing Heart: Medical, Device and Mechanical Methods

Heart failure is a progressive disease with significant morbidity and mortality, but prognostication often is difficult. Many of the evidence-based therapies for heart failure provide symptomatic benefit, but may have intolerable side effects for patients with advanced disease. At the end of life, there is evidence of varying strengths for pharmacologic and nonpharmacologic relief of common symptoms like dyspnea, fatigue, pain, and depression. Patients also may benefit from inotropic therapy, ventricular assist devices, and hospice care. It is important for physicians to encourage patients to formulate advance directives, including decisions about do not resuscitate orders and deactivation of implantable cardioverter-defibrillators and ventricular assist devices.

Marfan Syndrome and Quality of Life in the GenTAC Registry

Takotsubo cardiomyopathy is classically stress induced and characterized by regional wall motion abnormalities in the absence of coronary occlusion. It predominantly affects postmenopausal women; emotional and physical stressors can trigger the classic cardiomyopathic findings. These changes are likely mediated by catecholamines, which cause a distinctive pattern of ventricular dysfunction with a unique pathologic phenotype of apical ballooning. Underlying mood disorders increase the risk for developing takotsubo cardiomyopathy after a triggering event. Takotsubo cardiomyopathy is one of several brain-heart disorders; its unique pathology can shed light on the complex interactions between the brain, sympathetic nervous system, and the cardiovascular system.