Paulino Alvarez

Pulmonary Arterial Hypertension: Diagnosis and Treatment

Pulmonary arterial hypertension (PAH) is a specific, rare disease characterized by a well-described pattern of pulmonary vascular remodeling. The elevated pulmonary artery pressure in PAH results in increased right ventricular afterload, which, if untreated, leads rapidly to right ventricular failure and death. Recent marked expansion in knowledge about PAH has resulted in the development of effective therapies that improve quality of life and survival. However, delays in diagnosis and suboptimal treatment remain significant barriers to achieving optimal patient outcomes. Continued success in raising PAH awareness, earlier diagnosis, and the availability of new therapies mean a promising future for PAH patients.

Vortex Formation Time Index in Patients With Hypertrophic Cardiomyopathy

Vortex ring formation in early diastole helps with left ventricular (LV) filling without an increase in left atrial (LA) pressure. Vortex formation time (VFT) is a dimensionless parameter derived from LV geometry and indexes of LV systolic and diastolic performance [(1)][1]. The optimal range was

Acquired and Hereditary Hypercoagulable States in Patients with Continuous Flow Left Ventricular Assist Devices: Prevalence and Thrombotic Complications

BACKGROUND Thrombotic events in patients with continuous flow left ventricular assist devices (CF-LVADs) are associated with significant morbidity and mortality. The objective of this study was to delineate the frequency, clinical characteristics, and outcomes of patients with hypercoagulable states who undergo CF-LVAD implantation. METHODS We performed a retrospective review of 168 consecutive patients who underwent CF-LVAD implantation between 2010 and 2013. Chart and laboratory data were reviewed for the presence of a hereditary and/or acquired hypercoagulable state. Adverse outcomes were defined as death, confirmed pump thrombosis, aortic root clot, stroke, deep vein thrombosis, and pulmonary embolism. Fishers exact test and Kaplan-Meier estimate were used to analyze frequency of adverse outcomes and event free survival, respectively. RESULTS A hypercoagulable state was identified in 20 patients (11.9%). There were 18 patients with acquired, 1 with a congenital, and 1 with both congenital and acquired hypercoagulable states. The median follow-up was 429 days and 475 days in patients with and without hypercoagulable states, respectively. During the study period, 15% (3/20) of the patients with a hypercoagulable state had a diagnosis of deep vein thrombosis vs 3% (4/148) of the patients without a hypercoagulable state (P = .030). Only patients with a hypercoagulable state had a subarachnoid hemorrhage (3/20 vs 0/148; P < .01). The event-free survival was lower in the patients with hypercoagulable states (P = .005). CONCLUSION Hypercoagulable states are not uncommon in patients with CF-LVADs and may be associated with increased morbidity. Prospective studies are needed to more accurately identify the incidence, prevalence, and significance of hypercoagulable states in patients being considered for CF-LVAD.

Exercise And Heart Failure: Advancing Knowledge And Improving Care

Exercise limitation is the hallmark of heart failure, and an increasing degree of intolerance is associated with poor prognosis. Objective evaluation of functional class (e.g., cardiopulmonary exercise testing) is essential for adequate prognostication in patients with advanced heart failure and for implementing an appropriate exercise training program. A graded exercise program has been shown to be beneficial in patients with heart failure and has become an essential component of comprehensive cardiac rehabilitation in these patients. An exercise program tailored to the patients preferences, possibilities, and physiologic reserve has the greatest chance of being successful. Despite being safe, effective, and a guideline-recommended treatment to improve quality of life, exercise training remains grossly underutilized. Patient, physician, insurance and practice barriers need to be addressed to improve this quality gap.

Left ventricular function in patients with hypertrophic cardiomyopathy and its relation to myocardial fibrosis and exercise tolerance

We sought to determine the relation between myocardial extracellular volume (ECV), left ventricular (LV) diastolic function, and exercise tolerance in patients with hypertrophic cardiomyopathy (HCM). Forty five HCM patients with an ejection fraction >50% and no previous septal reduction therapy underwent imaging by CMR and transthoracic echocardiography. CMR was used to quantify LV volumes, mass, EF, LA volumes, scar burden, pre and post contrast T1 relaxation times and ECV. Echocardiography was used to measure outflow tract gradients, mitral inflow and annular velocities, circumferential strain, systolic, early and late diastolic strain rates. Exercise duration and peak oxygen consumption were noted. HCM patients had increased native T1 relaxation time and ECV vs. controls [ECV controls: 24.7 (23.2–26.4) vs. HCM: 26.8 (24.6–31.3)%, P = 0.014]. Both parameters were significantly associated with LV diastolic dysfunction, circumferential strain, diastolic strain rate and peak oxygen consumption (r = −0.73, P < 0.001). Compared to controls, HCM patients have significantly longer native T1 relaxation time and higher ECV. These structural changes lead to worse LV global and segmental diastolic function and in turn reduced exercise tolerance.

IN-HOSPITAL USE OF POTENTIALLY HARMFUL DRUGS IN HEART FAILURE: IMPACT ON LENGTH OF STAY AND MORTALITY

To evaluate prevalence of in-hospital use of potentially harmful drugs (PHD) in heart failure (HF) patients and analyze their impact on length of stay and in-hospital mortality. The University HealthSystem Consortium Database was queried for admissions with the primary diagnosis of HF during 2011-

Medicaid Insurance and Psychosocial Status in Patients Evaluated for Heart Transplantation

Health insurance coverage, particularly Medicaid, has been a focal point in the national debate. Medicaid was designed to provide health care for vulnerable patients with limited financial resources; now, ironically, the program itself has become vulnerable [(1)][1] due to increasing health care

IN HOSPITAL USE OF NON-STEROIDAL ANTI-INFLAMMATORY AGENTS IN PATIENTS WITH A PRINCIPAL DIAGNOSIS OF HEART FAILURE IS ASSOCIATED WITH INCREASED LENGTH OF STAY AND 30-DAY READMISSION RATE

Non-Steroidal Anti-inflammatory Drugs (NSAIDs) are associated with increased risk of worsening heart failure. The objective of this study was to estimate the frequency and clinical consequences of in-hospital NSAIDs use among patients admitted with a principal diagnosis of heart failure.

EFFECTIVE ORIFICE AREA BY CARDIAC MAGNETIC RESONANCE FOR THE FUNCTIONAL ASSESSMENT OF BIOPROSTHETIC AORTIC VALVES

Effective orifice area (EOA) is the current practice for prosthetic valve functional evaluation. We hypothesized that phase contrast (PC) methods could be employed to describe the dynamic EOA, and compared to Doppler-derived EOA in patients with bioprosthetic aortic valves. We retrospectively