Lung ultrasound versus lung auscultation to detect pulmonary congestion in patients with advanced heart failure before discharge.

Heart failure

ORAL PRESENTATION

Guiding heart failure care by invasive hemodynamic measurements: Possible or useful?

In this issue of Circulation: Heart Failure , Drazner et al1 report the findings of their study on the relationship of right and left ventricular (LV) filling pressures in patients with heart failure and preserved LV ejection fraction (HFPEF) (also referred to as heart failure with preserved systolic function, diastolic heart failure). They noted good concordance (79%) in this patient population between right atrial pressure (RAP), indicative of right ventricular filling pressure, and pulmonary artery occlusive pressure (pulmonary capillary wedge pressure [PCWP]), indicative of LV filling pressure. These pressures, modulated by various loading and unloading maneuvers, ranged from low to normal to high. Nonconcordance was noted in only 21% of the measurements, and, in these, the PCWP did not match the elevation of RAP. Article see p 202 The weaknesses and limitations of this study are overshadowed by its strengths. PCWP is not a direct measurement of left atrial pressure, and RAP and PCWP are not direct measurements of right and LV filling pressures, respectively. But their relationships (RAP to right ventricular filling pressure; PCWP to left atrial pressure and LV filling pressure) are closely linked, and correlations are generally quite high,2–5 such that RAP and PCWP are routinely used in clinical medicine as respective indicators of right and LV filling pressures. Only 11 patients with HFPEF were studied by Drazner et al.1 However, the study was performed in an experienced laboratory by seasoned investigators of human heart failure, using the standard techniques to generate a spectrum of ventricular-loading conditions. The lead author has a noteworthy record of studying fundamental hemodynamic questions in human heart failure.6–9 The question itself, namely the relationship between right and left heart filling pressures, had not been adequately examined in HFPEF. The favorable concordance of right and left heart filling pressures …

Cardiac Autonomic Nerve Stimulation in the Treatment of Heart Failure

Section 13: Evaluation and Therapy for Heart Failure in the Setting of Ischemic Heart Disease

World Health Organization Pulmonary Hypertension Group 2: Pulmonary hypertension due to left heart disease in the adult—a summary statement from the Pulmonary Hypertension Council of the International Society for Heart and Lung Transplantation

Evaluating pulmonary congestion with lung ultrasound and the need to take the next steps in heart failure.

“It has long been an axiom of mine that the little things are infinitely the most important” — —Sherlock Holmes in “A Case of Identity” by Arthur Conan Doyle Cardiac resynchronization therapy (CRT) can have a profound therapeutic impact on appropriately selected patients. However, even when the current clinical guidelines for CRT1 are rigorously applied, the response rate is ≈70%. Nearly a third of patients who undergo implantation of a CRT device are clinical nonresponders and more may be “remodeling nonresponders.” An extensive body of literature reports on a wide variety of methods that can be better used to identify potential responders by measurement of mechanical dyssynchrony. Factors responsible for nonresponse include comorbid conditions, cardiac substrate, left ventricular (LV) lead location, and device programming. Comorbid conditions such as obstructive sleep apnea, right-sided heart failure, and type of intraventricular conduction delay should be considered at the preprocedural stage. Device programming may help minimize the number of nonresponders. Prediction of responders by invasive hemodynamic assessment is impractical for daily clinical practice. Cardiac magnetic resonance imaging is too expensive for routine use and is not an option for many patients who already have devices and need upgrades. The appeal of echocardiography for predicting responders by identifying mechanical dyssynchrony has been dampened by its limited reproducibility and poor predictive value.2 It is also impractical to perform echocardiography during implantations. The prolonged QRS duration (QRSd; electric dyssynchrony), as measured on a standard 12-lead ECG, remains the best method for identifying candidates for CRT. In an elegant and important study reported in this issue of Circulation , Sweeney and colleagues3 use the 12-lead ECG and show that, despite its apparent simplicity, analysis of the standard 12-lead ECG can yield both pitfalls and impressive rewards. Article see p 626 Current clinical guidelines specify a …

Comparison of left ventricular systolic and diastolic function in patients with idiopathic dilated cardiomyopathy and mild heart failure versus those with severe heart failure

Relation of Baseline Systolic Blood Pressure and Long-Term Outcomes in Ambulatory Patients With Chronic Mild to Moderate Heart Failure

Application of mechanical cardiac support now requires consideration of a wider range of goals beyond bridging to transplantation to include destination therapy and perhaps bridging to recovery.1,2 Responsible dissemination of the technology requires identification of patient populations from which to select candidates most likely to benefit. At this early stage, benefit is most apparent against a high background mortality from end-stage heart failure. Heart failure affects an estimated 5 million patients in the United States. Of those, ≈60% have heart failure with left ventricular dilation and reduced ejection fraction. Trials demonstrating benefit of therapies for heart failure have focused primarily on mild–moderate heart failure with reduced ejection fraction, generally with annual mortality in the range of 8% to 18%.3 Advanced heart failure has been defined as symptoms limiting daily activity (New York Heart Association class III and IV) despite attempted therapy with angiotensin-converting enzyme inhibitors, β-blockers, digoxin, and diuretics,4 a description that applies to ≈300 000 to 800 000 patients in the United States. Although often labeled as “refractory,” many patients enjoy improved quality of life and decreased hospitalizations after referral to experienced heart failure centers, where aggressive medical strategies focus on relief of congestion. Surgical approaches include complex revascularization, valvular repair/replacement, or ventricular reconstruction. When technically successful, biventricular pacing can improve functional status for many of the 25% to 40% of patients with marked ventricular asynchrony.5 If early stabilization allows institution of β-adrenergic–blocking agents, prognosis is further improved.6 Dedicated heart failure management programs that facilitate patient education, compliance, and fluid balance have been integral to benefits observed with these therapies. The highest-risk heart failure populations are best identified after optimization of current therapies. Low left ventricular ejection fraction is not sufficient description of either function or prognosis once heart failure has become advanced. Neither …

Decongestion and Outcomes in Patients Hospitalized for Acute HeartFailure: Insights From the RELAX-AHF-2 Trial.

Heart failure is a deadly disease that has reached epidemic proportions in industrialized countries. Patients living with heart failure carry a heavy burden in terms of morbidity. Many patients require repeated hospitalizations for cardiovascular problems, especially for episodes of worsening heart failure. In fact, heart failure is one of the most important causes of hospital admissions in the United States, accounting for over 2.5 million admissions per year. Once hospitalized, patients with heart failure have an increased risk of recurrent hospitalizations and death. Approximately 30% to 40% of patients are readmitted within 6 months of an index hospitalization. Angiotensin-converting enzyme (ACE) inhibitors, digitalis, and spironolactone decrease the risk of hospitalization in heart failure patients; however, the annual rate of hospital admission for worsening heart failure has remained high.1–3⇓⇓ See p 2194 Given these challenges, clinical trials conducted in the mid 1990s that demonstrated that β-blocker therapy in addition to ACE inhibitors and digitalis reduces the risk of hospitalization in heart failure patients by about 20% to 30% represented remarkable progress. These beneficial effects of β-blocking agents on morbidity were recognized well before favorable effects on survival were unequivocally established (Table). In some, but not all, trials, the clinical benefits of β-blocker treatment included improved heart failure symptoms as assessed by physicians and patients. View this table: Large-Scale Clinical Trials Reporting β-Blocker Effects on Heart Failure Morbidity Previous trials addressing the effects of β-blockers on morbidity have been conducted in patients …

Congestive heart failure as an indication for continuous renal replacement therapy