Nancy Luo

Usefulness of Palliative Care to Complement the Management of Patients on Left Ventricular Assist Devices

Within the last decade, advancements in left ventricular assist device therapy have allowed patients with end-stage heart failure (HF) to live longer and with better quality of life. Like other life-saving interventions, however, there remains the risk of complications including infections, bleeding episodes, and stroke. The candidate for left ventricular assist device therapy faces complex challenges going forward, both physical and psychological, many of which may benefit from the application of palliative care principles by trained specialists. Despite these advantages, palliative care remains underused in many advanced HF programs. Here, we describe the benefits of palliative care, barriers to use within HF, and specific applications to the integrated care of patients on mechanical circulatory support.

Multinational and multiethnic variations in health-related quality of life in patients with chronic heart failure

Background Assessing health‐related quality of life (HRQoL) in patients with heart failure (HF) is an important goal of clinical care and HF research. We sought to investigate ethnic differences in perceived HRQoL and its association with mortality among patients with HF and left ventricular ejection fraction ≤35%, controlling for demographic characteristics and HF severity. Methods and results We compared 5697 chronic HF patients of Indian (26%), white (23%), Chinese (17%), Japanese/Koreans (12%), black (12%), and Malay (10%) ethnicities from the HF‐ACTION and ASIAN‐HF multinational studies using the Kansas City Cardiomyopathy Questionnaire (KCCQ; range 0–100; higher scores reflect better health status). KCCQ scores were lowest in Malay (58 ± 22) and Chinese (60 ± 23), intermediate in black (64 ± 21) and Indian (65 ± 23), and highest in white (67 ± 20) and Japanese or Korean patients (67 ± 22) after adjusting for age, sex, educational status, HF severity, and risk factors. Self‐efficacy, which measures confidence in the ability to manage symptoms, was lower in all Asian ethnicities (especially Japanese/Koreans [60 ± 26], Malay [66 ± 23], and Chinese [64 ± 28]) compared to black (80 ± 21) and white (82 ± 19) patients, even after multivariable adjustment (P < .001). In all ethnicities, KCCQ strongly predicted 1‐year mortality (HR 0.45, 95% CI 0.30–0.67 for highest vs lowest quintile of KCCQ; P for interaction by ethnicity .101). Conclusions Overall, HRQoL is inversely and independently related to mortality in chronic HF but is not modified by ethnicity. Nevertheless, ethnic differences exist independent of HF severity and comorbidities. These data may have important implications for future global clinical HF trials that use patient‐reported outcomes as endpoints.

Plasma acylcarnitines are associated with pulmonary hypertension

Quantifying metabolic derangements in pulmonary hypertension (PH) by plasma metabolomics could identify biomarkers useful for diagnosis and treatment. The objective of this paper is to test the hypotheses that circulating metabolites are differentially expressed in PH patients compared with controls and among different hemodynamic subtypes of PH associated with left heart disease. We studied patients enrolled in the CATHGEN biorepository with PH (right heart catheterization mPAP ≥ 25 mmHg; n = 280). Of these, 133 met criteria for postcapillary PH, 82 for combined precapillary and postcapillary PH (CpcPH), and 65 for precapillary PH. Targeted profiling of 63 metabolites (acylcarnitines, amino acids, and ketones) was performed using tandem flow injection mass spectrometry. Multivariable linear regression was used to determine differences in metabolite factors derived from a principal components analysis between PH cases, PH subtypes, and non-PH controls. In adjusted models, the metabolite factor loaded with long-chain acylcarnitines was higher in all PH cases versus non-PH controls (P = 0.00008), but did not discriminate between CpcPH and postcapillary PH (P = 0.56). In analyses of subtypes, CpcPH patients had lower levels of factors loaded with urea cycle amino acids and short chain acylcarnitines as compared to controls (P = 0.002 and P = 0.01, respectively) and as compared to postcapillary PH (P = 0.04 and P = 0.02, respectively). Compared to controls, PH was strongly associated with greater concentrations of long-chain acylcarnitines. Postcapillary PH and CpcPH were weakly associated with distinct metabolomic profiles. These findings suggest the presence of unique metabolic abnormalities in subtypes of PH and may reflect underlying pathophysiology.

Relationship between changing patient-reported outcomes and subsequent clinical events in patients with chronic heart failure: insights from HF-ACTION

A 5‐point change in the Kansas City Cardiomyopathy Questionnaire (KCCQ) is commonly considered to be a clinically significant difference in health status in patients with heart failure. We evaluated how the magnitude of change relates to subsequent clinical outcomes.

Reply: Adoption of Sacubitril/Valsartan Must Take Into Account Different Heart Failure Patient Types

We appreciate the interest by Drs. Di Tano and Bettari in our recent publication [(1)][1]. We thank the authors for highlighting that our report included patients discharged after an acute heart failure (HF) hospitalization, a population different from those studied in the PARADIGM-HF (Prospective

TEMPORARY REMOVAL: Early Impact of Guideline Publication on Angiotensin-Receptor Neprilysin Inhibitor Use among Patients Hospitalized for Heart Failure

Background: On May 20, 2016, US professional organizations in cardiology published joint treatment guidelines recommending the use of angiotensin‐receptor neprilysin inhibitor (ARNI) for eligible patients with heart failure with reduced ejection fraction (HFrEF). Using data from the Get With The Guidelines–Heart Failure registry, we evaluated the early impact of this update on temporal trends in ARNI prescription. Methods: We analyzed patients with HFrEF who were eligible for ARNI prescription (EF ≤40%, no contraindications) and hospitalized from February 20, 2016, through August 19, 2016—allowing for 13 weeks before and after guideline publication. We quantified trends in ARNI use associated with guidelines publication with an interrupted time‐series design using logistic regression and accounting for correlations within hospitals using general estimating equation methods. Results: Of 7,200 eligible patient hospitalizations, 51.9% were discharged in the period directly preceding publication of the guidelines, and 48.1% were discharged after. Odds ratios of ARNI prescription at discharge were significantly higher in the postguideline period compared with the preguideline period in adjusted models (adjusted odds ratio 1.29, 95% CI 1.06‐1.57, P = .01). However, there was no significant interaction between observed and expected ARNI use after guideline publication (Pinteraction = .14). Results were consistent using a 6‐month before and after time frame. Conclusions: The model suggested a small increase in ARNI use in HF patients being discharged from the hospital immediately after guideline release. However, the publication of national guidelines recommending ARNI use seemed to have little influence on the adoption of this evidence‐based medication in the first 3 to 6 months.

A Gordian knot: disentangling comorbidities in heart failure.

Recent advances in drug therapies have renewed hope and highlighted the steady reduction in mortality among patients with heart failure (HF) with reduced ejection fraction (HFrEF) over the last few decades.1 Nevertheless, more than 15 million Europeans and 6 million Americans live with HF; 50% will be dead at 5 years.2,3 Patients with HF with preserved ejection fraction (HFpEF) fare no better, and disease prevalence is only increasing as the population ages.4 There is no specific disease-modifying treatment that demonstrably improves HFpEF outcomes. As a group, patients with HFpEF have an increased burden of hypertension, diabetes, and anaemia, and die more frequently from non-cardiovascular death compared with HFrEF patients.2 However, these and other comorbidities are closely interrelated to both HFpEF and HFrEF.5 As such, defining, understanding, and targeting comorbidities have been advocated as a strategy that could improve patient outcomes across clinical spectrums.6 Writing in this context, Triposkiadis et al.7 provide in this issue of the Journal a tour de force overview of both cardiac and non-cardiac comorbidities in HF patients. They review the epidemiology, implications for treatment, and associations with outcomes in HF patients for the following comorbidities: hypertension, coronary artery disease, atrial fibrillation, chronic obstructive pulmonary disease, anaemia, diabetes, chronic kidney disease, sleep-disordered breathing, obesity, and depression. The authors synthesize an overwhelming amount of material in a concise manner and are to be commended. This review is unique in several aspects. Beyond summarizing epidemiology and outcomes data, they have systematically provided the pathophysiological link, when available, between each comorbidity and its effect on cardiac structure and function. In addition, the authors address highly prevalent disease processes that have a significant impact on patient quality of life but that are frequently overlooked by previous reports, such as obesity and depression.

TRP Channels in Cardiovascular Disease

Abstract Transient receptor potential (TRP) channels comprise a large superfamily of channels activated under conditions associated with cellular stress including stretch, neurohormonal signaling, hypoxia, and oxidative stress. Although often considered to be operative in nonexcitable cells, emerging data suggests that these channels are critically important to the function of cells in the heart and vasculature. Dysregulation of these channels during cardiac stress contributes to the maladaptive response during cardiac disease. Here, we consider the role of the TRP channels in cardiac failure, arrhythmogenesis, and pulmonary arterial hypertension. We discuss the importance of specific channels, the signaling cascades activated by TRP channels, and potential therapeutic agents. Thus, the case is building that selective and specific antagonism of TRP channels will become an important goal.