Kunal Bhatt

Depression in heart failure: Can PHQ-9 help?

BACKGROUND The Patient Health Questionnaire 9 (PHQ-9) is an effective tool for identification and grading of depression symptoms. Data on PHQ-9 utility for patients with heart failure (HF) are limited. METHODS We evaluated the severity of depression by PHQ-9 at baseline and its association with health care resource utilization (HCRU) rates and quality of life (QoL) in 308 outpatients enrolled in a prospective HF cohort study. Depression symptoms were stratified according to PHQ-9 score as minimal (0-4), mild (5-9), or moderate-to-severe (10-27). RESULTS Mean age of patients was 57±11years; 65% were men; 50% were white and 47% black; ejection fraction was 30±15%. Over 24±12months (total: 625person-years), there were 41 (13.3%) major clinical events (34 deaths, 5 transplants, 2 ventricular assist device implantations), 633 all-cause admissions (249 [39.3%] for HF), and 362 emergency department (ED) visits. Moderate-to-severe depressive symptoms were associated with 70% more all-cause admissions compared to patients without depressive symptoms and 2.5 times more HF-related admissions. However, less than 50% of patients with moderate-to-severe symptoms were on antidepressants. In adjusted analyses, even mild depressive symptoms were associated with 57% more all-cause admissions compared to patients without depressive symptoms and more than 2-fold higher rate of HF-related admissions. Depressive symptoms were not associated with ED visits. Increasing PHQ-9 score was associated with progressively worse QoL. PHQ-9 was not associated with major clinical events. CONCLUSIONS PHQ-9 effectively identifies HF patients at risk for increased HCRU and lower QoL. Interventions to reduce depression symptoms may help improve HF outcomes.

Myocardial Energetics and Heart Failure: a Review of Recent Therapeutic Trials

Purpose of reviewSeveral novel therapeutics being tested in patients with heart failure are based on myocardial energetics. This review will provide a summary of the recent trials in this area, including therapeutic options targeting various aspects of cellular and mitochondrial metabolism.Recent findingsAgents that improve the energetic balance in myocardial cells have the potential to improve clinical heart failure status. The most promising therapies currently under investigation in this arena include (1) elamipretide, a cardiolipin stabilizer; (2) repletion of iron deficiency with intravenous ferrous carboxymaltose; (3) coenzyme Q10; and (4) the partial adenosine receptor antagonists capadenoson and neladenosone.SummaryMyocardial energetics-based therapeutics are groundbreaking in that they utilize novel mechanisms of action to improve heart failure symptoms, without causing the adverse neurohormonal side effects associated with current guideline-based therapies. The drugs appear likely to be added to the heart failure therapy armamentarium as adjuncts to current regimens in the near future.

Racial differences in the development of de-novo donor-specific antibodies and treated antibody-mediated rejection after heart transplantation

BACKGROUND Despite improvements in outcomes after heart transplantation, black recipients have worse survival compared with non-black recipients. The source of such disparate outcomes remains largely unknown. We hypothesize that a propensity to generate de-novo donor-specific antibodies (dnDSA) and subsequent antibody-mediated rejection (AMR) may account for racial differences in sub-optimal outcomes after heart transplant. In this study we aimed to determine the role of dnDSA and AMR in racial disparities in post-transplant outcomes. METHODS This study was a single-center, retrospective analysis of 137 heart transplant recipients (81% male, 48% black) discharged from Emory University Hospital. Patients were classified as black vs non-black for the purpose of our analysis. Kaplan-Meier and Cox regression analyses were used to evaluate the association between race and selected outcomes. The primary outcome was the development of dnDSA. Secondary outcomes included treated AMR and a composite of all-cause graft dysfunction or death. RESULTS After 3.7 years of follow-up, 39 (28.5%) patients developed dnDSA and 19 (13.8%) were treated for AMR. In multivariable models, black race was associated with a higher risk of developing dnDSA (hazard ratio [HR] 3.65, 95% confidence interval [CI] 1.54 to 8.65, p = 0.003) and a higher risk of treated AMR (HR 4.86, 95% CI 1.26 to 18.72, p = 0.021) compared with non-black race. Black race was also associated with a higher risk of all-cause graft dysfunction or death in univariate analyses (HR 2.10, 95% CI 1.02 to 4.30, p = 0.044). However, in a multivariable model incorporating dnDSA, black race was no longer a significant risk factor. Only dnDSA development was significantly associated with all-cause graft dysfunction or death (HR 4.85, 95% CI 1.89 to 12.44, p = 0.001). CONCLUSION Black transplant recipients are at higher risk for the development of dnDSA and treated AMR, which may account for racial disparities in outcomes after heart transplantation.

Errors in Electronic Health Record–Based Data Query of Statin Prescriptions in Patients With Coronary Artery Disease in a Large, Academic, Multispecialty Clinic Practice

Background With the recent implementation of the Medicare Quality Payment Program, providers face increasing accountability for delivering high‐quality care. Such pay‐for‐performance programs aim to leverage systematic data captured by electronic health record (EHR) systems to measure performance; however, the fidelity of EHR query for assessing performance has not been validated compared with manual chart review. We sought to determine whether our institutions methodology of EHR query could accurately identify cases in which providers failed to prescribe statins for eligible patients with coronary artery disease. Methods and Results A total of 9459 patients with coronary artery disease were seen at least twice at the Emory Clinic between July 2014 and June 2015, of whom 1338 (14.1%, 95% confidence interval 13.5–14.9%) had no statin prescription or exemption per EHR query. A total of 120 patient cases were randomly selected and reviewed by 2 physicians for further adjudication. Of the 120 cases initially classified as statin prescription failures, only 21 (17.5%; 95% confidence interval, 11.7–25.3%) represented true failure following physician review. Conclusions Sole reliance on EHR data query to measure quality metrics may lead to significant errors in assessing provider performance. Institutions should be cognizant of these potential sources of error, provide support to medical providers, and form collaborative data management teams to promote and improve meaningful use of EHRs. We propose actionable steps to improve the accuracy of EHR data query that require hypothesis testing and prospective validation in future studies.

ASSOCIATION OF APOLIPOPROTEIN B SUBFRACTIONS AND CORONARY ARTERY CALCIUM IN ASYMPTOMATIC PATIENTS WITH INTERMEDIATE CARDIOVASCULAR RISK

Apolipoprotein B (apoB) is an excellent risk predictor for cardiovascular events, but little is known about the intestinal apoB48 subtype compared with the hepatic apoB100 subtype. Coronary artery calcium (CAC) is an extremely specific tool to quantify subclinical atherosclerosis. This study aimed

FIRST DEMONSTRATION THAT HEPATIC APOB100 AND INTESTINAL APOB48 CO-LOCALIZE WITH MACROPHAGES IN HUMAN CAROTID ATHEROSCLEROTIC PLAQUES

We previously demonstrated the presence and localization of hepatic apoB100 and intestinal apoB48 in human carotid atherosclerotic plaques by immunoperoxidase, immunofluorescence (IF), immunoelectron microscopy, and western blot; however, co-localization of apoB48 and apoB100 with macrophages has

PROSPECTIVELY TRIGGERED, VOLUMETRIC CARDIAC COMPUTED TOMOGRAPHY ANGIOGRAPHY ON A 320 DETECTOR ROW PLATFORM, REDUCES LENGTH OF STAY AND RADIATION EXPOSURE COMPARED TO RADIONUCLIDE MYOCARDIAL PERFUSION IMAGING IN LOW RISK, SYMPTOMATIC PATIENTS PRESENTING TO THE EMERGENCY ROOM

Retrospectively gated CTA has demonstrated a reduction in length of stay (LOS), hospital cost, and radiation exposure in low risk, symptomatic patients presenting to the ER, compared to myocardial perfusion imaging (MPI). However, the benefits of volumetric CTA have not been evaluated in this