Maya Guglin

Cost of Ventricular Assist Devices: Can We Afford The Progress?

The societal cost of heart failure (HF) is matched by few other medical conditions. More than 670 000 new cases will be diagnosed this year.1 It commonly affects the aged and is associated with other chronic illnesses. Despite significant improvements in outcomes associated with contemporary medical and electric therapies, HF tends to be a progressive condition with a median survival of only 2 to 3 years after diagnosis.2 In addition, HF is the second most costly condition for Medicare.3 The total expenditure on this disease in the United States is estimated between

Improvement in blood glucose control in patients with diabetes after implantation of left ventricular assist devices.

20 to

Obesity paradox in heart failure: statistical artifact, or impetus to rethink clinical practice?

39 billion,1,4,5 which corresponds to 1.5% to 4% of total health care costs.6 Further, the majority of medical financial resources are consumed in the final 2 years of life, a cost estimated at nearly

How to increase the utilization of donor hearts

155 000.7 Patients with advanced HF failing optimal treatments have limited therapeutic options. A small subset may qualify for cardiac transplantation, but stringent candidacy criteria and a limited supply of donor hearts limits its value to the larger HF population. In the past 5 years, improvements in left ventricular assist devices (LVAD) have made this a viable option to bridge a patient to transplant (BTT) or as permanent therapy (Destination Therapy, DT). The inability to define the size of the population that may ultimately be candidates for VAD therapy, particularly as DT, has led to widespread angst about the health care cost implications of this technology. The primary focus of this article is to critically review the available literature on the cost of VADs as well as alternative treatments for advanced HF. Patients with advanced HF have a 1-year survival of only 10% to 25%.8 Initial clinical trials of older pulsatile flow LVADs used as destination therapy demonstrated 1-year survival of …

Discharge BNP is a stronger predictor of 6-month mortality in acute heart failure compared with baseline BNP and admission-to-discharge percentage BNP reduction

Some reports suggest that the course of diabetes mellitus (DM) in heart failure (HF) may improve after implantation of left ventricular assist devices (LVADs). The objective of our study was to explore longitudinal changes in glycosylated hemoglobin (HbA1C) in patients with diabetes mellitus with advanced HF post-LVAD implantation. We retrospectively reviewed the records of all patients who received LVADs at our institution between 2002 and 2012 and selected those who 1) survived posthospital discharge and 2) had DM. We collected data on HbA1C before and after implantation of LVADs, daily doses of insulin, and antidiabetic drugs. Comparisons were done using Student’s t-test. A total of 50 patients met the inclusion criteria. HbA1C was 7.6 ± 1.6 before LVAD, 5.7 ± 0.9 within 3 months after the LVAD implant (p = 0.0001), 6.1 ± 1.0 (p = 0.004 in comparison with pre-LVAD level) in 3–6 months after the implant, 6.3 ± 1.0 (p = 0.01) in 6–9 months, and 5.3 ± 0.1 in 9–12 months (p = 0.002). There were no significant changes in body mass index. Favorable changes in clinical course of diabetes in patients with HF occur after the implantation of LVADs, persist for at least 1 year after the implant, and are likely associated with improved hemodynamics and metabolism after normalization of cardiac output.

Computerized auditory cognitive training to improve cognition and functional outcomes in patients with heart failure: Results of a pilot study

The “obesity paradox” in heart failure (HF) is a phenomenon of more favorable prognosis, especially better survival, in obese versus normal-weight HF patients. Various explanations for the paradox have been offered; while different in their details, they typically share the premise that obesity per se is not actually the cause of reduced mortality in HF. Even so, there is a lingering question of whether clinicians should refrain from, or at least soft-pedal on, encouraging weight loss among their obese HF patients. Against the backdrop of recent epidemiological analysis by Banack and Kaufman, which speculates that collider stratification bias may generate the obesity paradox, we seek to address the aforementioned question. Following a literature review, which confirms that obese HF patients are demographically and clinically different from their normal-weight counterparts, we present four hypothetical data sets to illustrate a spectrum of possibilities regarding the obesity–mortality association. Importantly, these hypothetical data sets become indistinguishable from each other when a crucial variable is unmeasured or unreported. While thorough, the discussion of these data sets is intended to be accessible to a wide audience, especially including clinicians, without a prerequisite of familiarity with advanced epidemiology. We also furnish intuitive visual diagrams which depict a version of the obesity paradox. These illustrations, along with reflection on the distinction between weight and weight loss (and, furthermore, between voluntary and involuntary weight loss), lead to our recommendation for clinicians regarding the encouragement of weight loss. Finally, our conclusion explicitly addresses the questions posed in the title of this article.

The Role of Biventricular Pacing in the Prevention and Therapy of Pacemaker-Induced Cardiomyopathy

Cardiac transplantation is the best treatment available for patients with end-stage cardiomyopathy. Shortage of donor hearts is the main factor limiting the use of this treatment. Many donor hearts are rejected for transplantation because of left ventricular (LV) systolic dysfunction and/or wall motion abnormalities. While some donors have true cardiomyopathy, a significant proportion has reversible LV dysfunction due to neurogenic stunned myocardium. This condition is triggered by excess of catecholamines, which is typical for brain-dead donors. If given time to recover, LV function may improve, and the heart will be suitable for transplantation. Moreover, limiting of exogenous catecholamines may facilitate the recovery. In this review, we summarize the data on LV dysfunction/wall motion abnormalities in heart donors and propose the strategy to increase the utilization of donor hearts.

Abnormal contractility in human heart myofibrils from patients with dilated cardiomyopathy due to mutations in TTN and contractile protein genes

INTRODUCTION Prior studies found a significant relationship between admission B-type natriuretic peptide (BNP), discharge BNP and admission-to-discharge percentage BNP reduction and post-discharge mortality in acute heart failure (HF). METHODS The ESCAPE trial data was utilized to identify which of these BNP parameters best predicts 6-month all-cause mortality. RESULTS 433 patients (mean age 56years, 74% men) included in our analysis had an admission BNP, discharge BNP and admission-to-discharge percentage BNP reduction of 1009pg/mL, 743pg/mL and -70%, respectively. There were significant differences between survivors and nonsurvivors with regards to admission BNP (P=0.001), discharge BNP (P=0.0001) and admission-to-discharge percentage BNP reduction (P=0.01). Discharge BNP had the highest area under the curve (AUC) for predicting mortality (AUC=0.702, P<0.001) followed by admission BNP (AUC=0.633, P=0.0006) then percentage BNP reduction (AUC=0.620, P=0.008). Comparison of AUC revealed a significant difference between discharge BNP and admission BNP (difference between areas 0.087, P=0.0223) and a trend towards significance when comparing AUC of discharge BNP with percentage BNP reduction (P=0.0637). Kaplan-Meier analysis showed a significant difference in survival according to optimum cutoff values of discharge BNP of 319pg/mL (log-rank P<0.001), admission BNP of 912pg/mL (P<0.001) and percentage BNP reduction of 7.71% (P=0.008). Cox-proportional-hazard-analysis revealed that discharge BNP is an independent predictor of 6-month mortality (hazard ratio=1.063, 95% CI=1.037-1.089, P<0.001). The combination of a discharge BNP ≤319pg/mL and percentage BNP reduction ≥7.71% was associated with significantly lower mortality (4.8% versus 27.2%, relative risk=0.134, 95% CI=0.046-0.387, P<0.001). CONCLUSION The absolute BNP value at discharge is a more accurate predictor of 6-month mortality than the magnitude of percentage in-hospital BNP reduction and baseline BNP.

Lisinopril or Coreg CR in reducing cardiotoxicity in women with breast cancer receiving trastuzumab: A rationale and design of a randomized clinical trial

OBJECTIVES Feasibility and efficacy of computerized auditory cognitive training (ACT) was examined among patients with heart failure (HF). BACKGROUND Individuals with HF have four times increased risk of cognitive impairment, yet cognitive intervention studies are sparse. METHODS A pilot randomized controlled design was used. RESULTS The ACT group (n = 9) and control group (n = 8) had similar baseline characteristics. Seven participants (78%) completed ≥ 18 hours of ACT. Medium effect sizes were observed for improved cognition as indicated by auditory processing speed (d = 0.78), speech processing (d = 0.88), and working memory (d = 0.44-0.50). Small effect sizes were found for improved functional outcomes including HF selfcare (d = 0.34), Timed Instrumental Activities of Daily Living (d = 0.32), Six-Minute Walk Test (d = 0.38) and Short-Form-36 (d = 0.22) relative to controls. CONCLUSION Results indicated ACT is feasible among persons with HF. Despite a small sample size, ACT showed potential for improved speed of processing and working memory and improved functional outcomes, and warrants further exploration.

Heart Failure as a Risk Factor for Diabetes Mellitus

Right ventricular (RV) pacing produces well‐known long‐term deleterious effects not only on already compromised, but also on the normal left ventricle (LV). The activation pattern mimicks that of left bundle branch block, with delayed activation of the LV free wall, and results in electrical and mechanical dyssynchrony. Long‐term mandatory (100%) RV pacing, increases LV dimensions and decreases the ejection fraction. Many of these negative effects of pacing can be overcome by biventricular pacing. In this review, we describe the characteristics of pacemaker‐induced cardiomyopathy, its incidence, and the use of cardiac resynchronization therapy (CRT) for its therapy and prevention. The gaps in the current organizational guidelines for using CRT in the treatment of bradycardia are identified, and goals for future research are discussed.