Thomas D. Stamos

Six Minute Walk Test Predicts Long-Term All-Cause Mortality and Heart Failure Rehospitalization in African-American Patients Hospitalized With Acute Decompensated Heart Failure

BACKGROUND The prognostic value of the 6-minute walk test (6MWT) has been described in patients with heart failure (HF); however, limited data are available in an African-American (AA) population. We prospectively evaluated the usefulness of the 6MWT in predicting mortality and HF rehospitalization in AA patients with acute decompensated HF. METHODS AND RESULTS Two hundred AA patients (63.1% men, mean age 55.7 +/- 12.9 years) with acute decompensated HF were prospectively studied. Patients were followed to assess 40-month all-cause mortality and 18-month HF rehospitalization. The median distance walked on the 6MWT was 213 m. Of the 198 patients with available mortality data, 59 patients (29.8%) died. Of the 191 patients with available rehospitalization data, 114 (59.7%) were rehospitalized for worsening HF. For patients who walked <or=200 m during the 6MWT, mortality was 41% compared with 19% in patients who walked >200 m (P = .001). For patients who walked <or=200 m during the 6MWT, HF rehospitalization was 68% compared with 52% in those who walked >200 m (P = .027). Multivariate Cox regression analysis showed that 6MWT distance <or=200 m was the strongest predictor of mortality (adjusted hazard ratio [HR], 2.14; confidence interval [CI], 1.20 to 3.81; P = .01) and HF rehospitalization (adjusted HR, 1.62; CI, 1.10 to 2.39; P = .015). CONCLUSIONS In AA patients hospitalized with acute decompensated HF, 6MWT strongly and independently predicts long-term all-cause mortality and HF rehospitalization.

Feasibility of implementing a comprehensive warfarin pharmacogenetics service.

To determine the procedural feasibility of a pharmacist‐led interdisciplinary service for providing genotype‐guided warfarin dosing for hospitalized patients newly starting warfarin.

Association of Aldosterone Concentration and Mineralocorticoid Receptor Genotype with Potassium Response to Spironolactone in Patients with Heart Failure

Study Objective. To identify patient‐specific factors associated with spironolactone‐induced potassium level elevation in patients with heart failure.

Cardiovascular Disease Among Hispanics and Non-Hispanics in the Chronic Renal Insufficiency Cohort (CRIC) Study

BACKGROUND AND OBJECTIVES Hispanics are the largest minority group in the United States. The leading cause of death in patients with chronic kidney disease (CKD) is cardiovascular disease (CVD), yet little is known about its prevalence among Hispanics with CKD. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We conducted cross-sectional analyses of prevalent self-reported clinical and subclinical measures of CVD among 497 Hispanics, 1638 non-Hispanic Caucasians, and 1650 non-Hispanic African Americans, aged 21 to 74 years, with mild-to-moderate CKD at enrollment in the Chronic Renal Insufficiency Cohort (CRIC) and Hispanic CRIC (HCRIC) studies. Measures of subclinical CVD included left ventricular hypertrophy (LVH), coronary artery calcification (CAC), and ankle-brachial index. RESULTS Self-reported coronary heart disease (CHD) was lower in Hispanics compared with non-Hispanic Caucasians (18% versus 23%, P = 0.02). Compared with non-Hispanic Caucasians, Hispanics had a lower prevalence of CAC >100 (41% versus 34%, P = 0.03) and CAC >400 (26% versus 19%, P = 0.02). However, after adjusting for sociodemographic factors, these differences were no longer significant. In adjusted analyses, Hispanics had a higher odds of LVH compared with non-Hispanic Caucasians (odds ratio 1.97, 95% confidence interval, 1.22 to 3.17, P = 0.005), and a higher odds of CAC >400 compared with non-Hispanic African Americans (odds ratio, 2.49, 95% confidence interval, 1.11 to 5.58, P = 0.03). Hispanic ethnicity was not independently associated with any other CVD measures. CONCLUSIONS Prevalent LVH was more common among Hispanics than non-Hispanic Caucasians, and elevated CAC score was more common among Hispanics than non-Hispanic African Americans. Understanding reasons for these racial/ethnic differences and their association with long-term clinical outcomes is needed.

The use of echocardiography in the critical care setting

Echocardiography has become an invaluable tool in the management of critically ill patients. Its safety and portability allow for use at the bedside to provide rapid, detailed information regarding the cardiovascular system. Echocardiography can elucidate cardiac structure and mechanical function. Recently, the power of clinical echocardiography has been augmented by the use of Doppler techniques to evaluate cardiovascular hemodynamics. An in-depth understanding of the proper use of echocardiography is a prerequisite for the intensivist.

Comparison of Rate Control versus Rhythm Control for Management of Atrial Fibrillation in Patients with Coexisting Heart Failure: A Cost-Effectiveness Analysis

Study Objective. To compare lifetime costs and health outcomes of rate control versus rhythm control for management of atrial fibrillation in patients with coexisting heart failure from the third‐party payer perspective.

Flexible Diuretic Titration in Chronic Heart Failure: Where Is the Evidence?

BACKGROUND Several sets of heart failure (HF) consensus/guideline statements support the use of a flexible diuretic dosing regimen for HF outpatient management of fluid overload-related signs and symptoms. However, despite the widespread acceptance of such an approach, the evidence supporting the effectiveness of this approach in improving clinical outcomes is unknown. The primary objective of this manuscript was to summarize and review the evidence supporting the use of a flexible diuretic regimen in the management of outpatient heart failure patients. METHODS AND RESULTS A systematic review was performed, and 9 studies were identified relevant to the question of flexible diuretic titration in the setting of chronic heart failure. Among the 9 studies, 5 were randomized. Three of the randomized trials included flexible diuretic titration as part of a broader multifaceted disease management program, and only 2 were designed to specifically evaluate the sole contribution of flexible diuretic titration. Collectively, data from all of the studies reviewed supported the idea that flexible and individualized diuretic dosing is potentially associated with reduced emergency room visits, reduced rehospitalization, and improved quality of life in HF patients with reduced ejection fraction. CONCLUSIONS To date, only 2 randomized clinical studies were identified that were designed to determine the effects of a flexible diuretic dosing regimen in outpatient HF patients with reduced ejection fraction. Data are lacking in HF patients with preserved ejection fraction. There is a critical need to test this strategy in well designed prospective randomized clinical trials.

Carbohydrate Antigen 125 Predicts Long‐Term Mortality in African American Patients With Acute Decompensated Heart Failure

The goal of this study was to evaluate the relation between serum levels of carbohydrate antigen 125 (CA125) and prognosis in African American (AA) patients with heart failure (HF). Little is known about the usefulness of CA125 in the AA population, which has different pathophysiology and higher prevalence of HF. The authors enrolled 172 consecutive AA patients (mean age, 55.8 years; 61.1% men) admitted with a clinical diagnosis of acute decompensated HF. CA125 was measured within 48+/-12 hours of presentation. Patients were grouped according to CA125 levels into quartiles. The median CA125 level was 16 U/mL. Serum levels of CA125 were elevated (>35 U/mL) in 58 patients (33.7%). Fifty-two patients (30.8%) died over a median follow-up period of 40 months. The CA125 threshold derived from the receiver operating characteristic curves for the prediction of mortality was 35 U/mL. In a multivariate analysis, CA125 levels >35 U/mL were found to be predictive of 40-month all-cause mortality (adjusted hazard ratio, 2.53; confidence interval, 1.40-4.59; P=.002). However, CA125 levels were not associated with 18-month HF rehospitalization. CA125 value is a strong and independent predictor of long-term mortality in AA patients admitted with a diagnosis of acute decompensated HF. Identifying a higher-risk cohort might allow for a more targeted treatment approach.

Hospital compliance with performance measures and 30-day outcomes in patients with heart failure

BACKGROUND In 2005, the American College of Cardiology/American Heart Association published performance measures to provide a standard of care for hospitalized patients with heart failure (HF). Despite increasing compliance with these measures, hospital mortality and readmission rates remain stagnant. Whether compliance with HF performance measures improves patient outcomes at the hospital level is unclear. METHODS We evaluated compliance with HF performance measures at 3,655 US hospitals. Patients admitted with a diagnosis of HF in 2008 were identified using the US Department of Health and Human Services Hospital Compare database. Compliance with 4 specific performance measures was examined: evaluation of left ventricular systolic function, administration of angiotensin-converting enzyme inhibitor I or angiotensin-receptor blocker for left ventricular systolic dysfunction, offering smoking cessation advice and counseling, and providing discharge instructions. Thirty-day mortality and readmission rate were recorded. RESULTS Hospitals reporting greater compliance with the 4 performance measures had significantly lower 30-day mortality rates. However, these hospitals were also located in areas of higher socioeconomic status and treated higher volumes of patients with HF. After adjusting for socioeconomic and hospital factors, only evaluation of left ventricular systolic function was associated with lower 30-day mortality, and evaluation of left ventricular systolic function and smoking cessation counseling were associated with lower readmission rates. CONCLUSIONS We found that socioeconomic factors and hospital volume were stronger predictors of mortality than compliance with HF performance measures. After adjusting for socioeconomic factors and hospital volume, only 1 of the 4 performance measures was associated with lower 30-day mortality and 2 were associated with lower readmissions.

Association of β-Blocker Dose with Serum Procollagen Concentrations and Cardiac Response to Spironolactone in Patients with Heart Failure

Study Objective. To determine whether β‐blocker dose influences cardiac collagen turnover and the effects of spironolactone on cardiac collagen turnover in patients with heart failure.