Control In Heart Failure Patients Research Articles

Heart failure causally affects the brain cortical structure: a Mendelian randomization study.

The effects of heart failure (HF) on cortical brain structure remain unclear. Therefore, the present study aimed to investigate the causal effects of heart failure on cortical structures in the brain using Mendelian randomization (MR) analysis. We conducted a two-sample MR analysis utilizing genetically-predicted HF trait, left ventricular ejection fraction (LVEF), and N-terminal prohormone brain natriuretic peptide (NT-proBNP) levels to examine their effects on the cortical surface area (SA) and thickness (TH) across 34 cortical brain regions. Genome-wide association study summary data were extracted from studies by Rasooly (1,266,315 participants) for HF trait, Schmidt (36,548 participants) for LVEF, the SCALLOP consortium (21,758 participants) for NT-proBNP, and the ENIGMA Consortium (51,665 participants) for cortical SA and TH. A series of MR analyses were employed to exclude heterogeneity and pleiotropy, ensuring the stability of the results. Given the exploratory nature of the study, p-values between 1.22E-04 and 0.05 were considered suggestive of association, and p-values below 1.22E-04 were defined as statistically significant. In this study, we found no significant association between HF and cortical TH or SA (all p > 1.22E-04). We found that the HF trait and elevated NT-proBNP levels were not associated with cortical SA, but were suggested to decrease cortical TH in the pars orbitalis, lateral orbitofrontal cortex, temporal pole, lingual gyrus, precuneus, and supramarginal gyrus. Reduced LVEF was primarily suggested to decrease cortical SA in the isthmus cingulate gyrus, frontal pole, postcentral gyrus, cuneus, and rostral middle frontal gyrus, as well as TH in the postcentral gyrus. However, it was suggested to causally increase in the SA of the posterior cingulate gyrus and medial orbitofrontal cortex and the TH of the entorhinal cortex and superior temporal gyrus. We found 15 brain regions potentially affected by HF, which may lead to impairments in cognition, emotion, perception, memory, language, sensory processing, vision, and executive control in HF patients.

Rate Versus Rhythm Control in Heart Failure Patients with Post-Operative Atrial Fibrillation After Cardiac Surgery

BackgroundWhether rhythm control for post-operative atrial fibrillation after cardiac surgery (POAF) is superior to rate control in patients with heart failure or systolic dysfunction (HF) is not known. MethodsWe performed a post-hoc analysis of a trial by the Cardiothoracic Surgical Trials Network, which randomized patients with POAF after cardiac surgery to rate control or rhythm control with amiodarone/cardioversion. We assessed subgroups of trial participants defined by heart failure/cardiomyopathy history or left ventricular ejection fraction (LVEF) < 50%. We conducted a stratified analysis in patients with and without HF to explore outcomes of rhythm versus rate control strategy. ResultsOf 523 subjects with POAF after cardiac surgery, 131 (25%) had HF. 49% of HF patients were randomized to rhythm control. In HF patients, rhythm control was associated with less atrial fibrillation within the first 7 days. There were no differences in rhythm at 30- and 60-day follow-up. In the HF group, there were significantly more subjects with AF < 48 hours in the rhythm control group compared to rate control group- 68.8% compared to 46.3%, P=0.009. By comparison, in the non-HF stratum, 54.4% of the rate control group had AF < 48 hours compared to 63.5% of the rhythm control group (P=0.067).), though there was no significant interaction of heart failure with cardiac rhythm at 7 days (Pinteraction 0.16). ConclusionRhythm control for HF patients with POAF after cardiac surgery increases early restoration of sinus rhythm. Rate and rhythm control are both reasonable for HF patients with AF after cardiac surgery

Rhythm Control in Heart Failure Patients with Atrial Fibrillation.

AF and heart failure (HF) commonly coexist. Left atrial ablation is an effective treatment to maintain sinus rhythm (SR) in patients with AF. Recent evidence suggests that the use of ablation for AF in patients with HF is associated with an improved left ventricular ejection fraction and lower death and HF hospitalisation rates. We performed a systematic search of world literature to analyse the association in more detail and to assess the utility of AF ablation as a non-pharmacological tool in the treatment of patients with concomitant HF.

Long-term prognostic role of diabetes mellitus and glycemic control in heart failure patients with reduced ejection fraction: Insights from the MECKI Score database

BackgroundThe prognostic role of diabetes mellitus (DM) in heart failure (HF) patients is undefined, since DM is outweighed by several DM-related variables when confounders are considered. We determined the prognostic role of DM, treatment, and glycemic control in a real-life HF population. Methods3927 HF patients included in the Metabolic Exercise Cardiac Kidney Index (MECKI) score database were evaluated with a median follow-up of 3.66 years (IQR 1.70–6.67). Data analysis considered survival between DM (n = 897) vs. non-DM (n = 3030) patients, and, in diabetics, between insulin (n = 304), oral antidiabetics (n = 479), and dietary only (n = 88) treatments. The role of glycemic control was evaluated grouping DM patients according to glycated hemoglobin (HbA1c): <7% (n = 266), 7.1–8% (n = 133), >8% (n = 149). All analyses were performed also adjusting for ejection fraction, renal function, hemoglobin, sodium, exercise peak oxygen uptake, and ventilation/carbon dioxide relationship slope. Study primary endpoint was the composite of cardiovascular death, urgent heart transplantation, or left ventricular assist device implantation. Secondary endpoints were cardiovascular and all causes death. ResultsFor all endpoints, upon adjustment for confounders, DM status and insulin treatment or dietary regimen were not significantly associated with adverse long-term prognosis compared to non-DM and oral antidiabetic treated patients, respectively. A worse prognosis was observed in HbA1c >8% patients (Log-Rank p < 0.001), even after correction for confounding factors. All results were replicated by hazard ratio analysis. ConclusionIn HF patients, DM, insulin treatment and dietary regimen are not adverse outcome predictors. The only condition related to long-term prognosis, considering potential confounders, is poor glycemic control.

P3517Failure to achieve adequate heart rate control in women during therapy optimization

Abstract Background Previous studies highlighted the importance of adequate heart rate control in heart failure patients, and suggested under-treatment with beta-blockers especially in women. However, data on women achieving effective heart rate control during beta-blocker therapy optimization are lacking. Methods The wearable cardioverter defibrillator (WCD) allows continuous monitoring of heart rate (HR) trends during WCD use. In the current study, we assessed resting HR trends (nighttime: midnight-7am) in women, both at the beginning of WCD use and at the end of WCD use to assess the adequacy of beta-blockade following a typical 3 months of therapy optimization with beta-blockers. An adequate heart rate control was defined as having a nighttime HR &lt;70 bpm at the end of the 3 months. Results There were a total of 21,453 women with at least 30 days of WCD use (&gt;140 hours WCD use on the first and last week). The mean age was 67 years (IQR 58–75). The mean nighttime heart rate was 72 bpm (IQR 65–81) at the beginning of WCD use, that decreased to 68 bpm (IQR 61–76) at the end of WCD use with therapy optimization. Women had an insufficient heart rate control with resting heart rate ≥70 bpm in 59% at the beginning of WCD use that decreased to 44% at the end of WCD use, but still remained surprisingly high. Interestingly, there were 21% of the women starting with HR ≥70 bpm at the beginning of use (BOU) who achieved adequate heart rate control by the end of use (EOU). Interestingly, 6% of women with adequate heart rate control at the start of therapy optimization ended up having higher heart rates &gt;70 bpm at the end of the therapy optimization time period (Figure). Figure 1 Conclusions A significant proportion of women with heart failure and low ejection fraction do not reach an adequate heart rate control during the time of beta blocker initiation/titration. The wearble cardioverter defibrillator is a monitoring device that has been demonstrated in this study to appropriately identify patients with inadequate heart rate control at the end of the therapy optimization period. The WCD could be utilized to improve management of beta-blocker therapy in women and improve the achievement of adequate heart rate control in women.

Failure to Achieve Adequate Heart Rate Control in Women during Therapy Optimization

Background Previous studies highlighted the importance of adequate heart rate control in heart failure patients, and suggested under-treatment with beta-blockers especially in women. However, data on women achieving effective heart rate control during beta-blocker therapy optimization are lacking. Methods The wearable cardioverter defibrillator (WCD) allows continuous monitoring of heart rate (HR) trends during WCD use. In the current study, we assessed resting HR trends (nighttime: midnight-7am) in women, both at the beginning of WCD use and at the end of WCD use to assess the adequacy of beta-blockade following a typical 3 months of therapy optimization with beta-blockers. An adequate heart rate control was defined as having a nighttime HR Results There were a total of 21,453 women with at least 30 days of WCD use (>140 hours WCD use on the first and last week). The mean age was 67 years (IQR 58-75). The mean nighttime heart rate was 72 bpm (IQR 65-81) at the beginning of WCD use that decreased to 68 bpm (IQR 61-76) at the end of WCD use with therapy optimization. Women had an insufficient heart rate control with resting heart rate ≥ 70 bpm in 59% at the beginning of WCD use that decreased to 44% at the end of WCD use, but still remained surprisingly high. Interestingly, there were 21% of the women starting with HR ≥ 70 bpm at the beginning of use (BOU) who achieved adequate heart rate control by the end of use (EOU). Interestingly, 6% of women with adequate heart rate control at the start of therapy optimization ended up having higher heart rates >70 bpm at the end of the therapy optimization time period (Figure). Conclusions A significant proportion of women with heart failure and low ejection fraction do not reach an adequate heart rate control during the time of beta blocker initiation/titration. The wearble cardioverter defibrillator is a monitoring device that has been demonstrated in this study to appropriately identify patients with inadequate heart rate control at the end of the therapy optimization period. The WCD could be utilized to improve management of beta-blocker therapy in women and improve the achievement of adequate heart rate control in women.

Catheter ablation of atrial fibrillation-A key role in heart failure therapy?

Atrial fibrillation (AF) and heart failure (HF) are epidemic cardiac diseases and are often detected in the same patient. Recent evidence suggests that this is not a mere coincidence but that the strategy of AF treatment may impact HF development. This review comprehensively summarizes current trial data on rhythm and rate control strategies in atrial fibrillation with a special focus on catheter ablation of AF in HF patients. For a long time, rate and rhythm control strategies for AF have been regarded as equal regarding long term mortality. Decision making has been based on the symptoms of patients. Current trials, however, show that the treatment strategy of AF and its effectiveness may significantly impact survival of HF patients. The benefits of rhythm control in HF patients may have been masked by side effects of antiarrhythmic drugs. If rhythm control, however, is achieved by catheter ablation, a reduction of HF related mortality can be observed. As catheter ablation of AF may reduce mortality in HF patients, AF ablation should be preferred over medical treatment in HF patients. In general, HF patients may profit most from rigorous AF treatment.

Improvement in glycemic control after left ventricular assist device implantation in advanced heart failure patients with diabetes mellitus.

Left ventricular assist devices (LVADs) have been shown to improve outcomes in advanced heart failure (HF). We hypothesized that LVADs improve glycemic control in HF patients with diabetes mellitus (DM). During a 6 year time period, 202 patients underwent mechanical circulatory support. Of these, 50 patients with DM were included. Data were collected within 2 months before LVAD implantation and at 5.6 ± 1.1 months post-LVAD implant. There was no significant difference in body mass index, hemoglobin, hematocrit, and renal function pre-LVAD and post-LVAD. Fasting blood glucose improved from 136 ± 35 to 108 ± 29 mg/dl post-LVAD (p < 0.001). In 18 patients taking insulin only, daily insulin dose decreased from 43 ± 37 to 29 ± 24 units (p = 0.02). Of the 17 patients taking oral hypoglycemic agents, four did not require antidiabetic medications, six continued the same dose, two required higher doses, and five patients were switched to insulin post-LVAD. In a subset of 22 patients with available data, hemoglobin A1c improved significantly post-LVAD (p < 0.001). C-reactive protein in a subset of 18 patients decreased post-LVAD (p = 0.059). In conclusion, diabetic patients with advanced HF appear to have significant improvement in glycemic control and require less antidiabetic medications post-LVAD.

Pharmacological Treatment of Atrial Fibrillation in Patients with Heart Failure

Atrial fibrillation (AF) frequently occurs in patients with heart failure. It is recognized that AF leads to clinical deterioration and results in worsening heart failure. AF also increases the risk of mortality and morbidity in patients with heart failure. ESC guideline 2010 introduces treatment recommendations for the management of AF in patients with heart failure. 1) Background heart failure treatment should be optimized, 2) Oral anticoagulant is generally indicated when AF is present, 3) Ventricular rate control is required. Beta-blockers are preferred over digitalis and have favorable effects on mortality and morbidity in patients with systolic heart failure. 4) The rhythm control strategy has not been shown to be superior to rate control in heart failure patients with AF (AF-CHF trial). However, restoration of sinus rhythm may improve symptoms and hemodynamics in heart failure patients with AF. Amiodarone can be safely used in patients with heart failure. In patients with AF and severe and unstable heart failure, intravenous amiodarone should be used to maintain sinus rhythm. The goal of pharmacological management is to improve in survival and quality of life in heart failure patients with AF. Atrial fibrillation (AF) frequently occurs in patients with heart failure. It is recognized that AF leads to clinical deterioration and results in worsening heart failure. AF also increases the risk of mortality and morbidity in patients with heart failure. ESC guideline 2010 introduces treatment recommendations for the management of AF in patients with heart failure. 1) Background heart failure treatment should be optimized, 2) Oral anticoagulant is generally indicated when AF is present, 3) Ventricular rate control is required. Beta-blockers are preferred over digitalis and have favorable effects on mortality and morbidity in patients with systolic heart failure. 4) The rhythm control strategy has not been shown to be superior to rate control in heart failure patients with AF (AF-CHF trial). However, restoration of sinus rhythm may improve symptoms and hemodynamics in heart failure patients with AF. Amiodarone can be safely used in patients with heart failure. In patients with AF and severe and unstable heart failure, intravenous amiodarone should be used to maintain sinus rhythm. The goal of pharmacological management is to improve in survival and quality of life in heart failure patients with AF.

A randomized pilot trial of remote ischemic preconditioning in heart failure with reduced ejection fraction.

BackgroundRemote ischemic preconditioning (RIPC) induced by transient limb ischemia confers multi-organ protection and improves exercise performance in the setting of tissue hypoxia. We aimed to evaluate the effect of RIPC on exercise capacity in heart failure patients.MethodsWe performed a randomized crossover trial of RIPC (4×5-minutes limb ischemia) compared to sham control in heart failure patients undergoing exercise testing. Patients were randomly allocated to either RIPC or sham prior to exercise, then crossed over and completed the alternate intervention with repeat testing. The primary outcome was peak VO2, RIPC versus sham. A mechanistic substudy was performed using dialysate from study patient blood samples obtained after sham and RIPC. This dialysate was used to test for a protective effect of RIPC in a mouse heart Langendorff model of infarction. Mouse heart infarct size with RIPC or sham dialysate exposure was also compared with historical control data.ResultsTwenty patients completed the study. RIPC was not associated with improvements in peak VO2 (15.6+/−4.2 vs 15.3+/−4.6 mL/kg/min; p = 0.53, sham and RIPC, respectively). In our Langendorff sub-study, infarct size was similar between RIPC and sham dialysate groups from our study patients, but was smaller than expected compared to healthy controls (29.0%, 27.9% [sham, RIPC] vs 51.2% [controls]. We observed less preconditioning among the subgroup of patients with increased exercise performance following RIPC (p<0.04).ConclusionIn this pilot study of RIPC in heart failure patients, RIPC was not associated with improvements in exercise capacity overall. However, the degree of effect of RIPC may be inversely related to the degree of baseline preconditioning. These data provide the basis for a larger randomized trial to test the potential benefits of RIPC in patients with heart failure.Trial RegistrationClinicalTrials.gov +++++NCT01128790

The Relationship Between Leptin and Ventilatory Control in Heart Failure

BackgroundIncreased serum leptin concentration has been linked to increased ventilation in patients with mild heart failure (HF). However, in animal models the absence of leptin has also been associated with increased ventilation. This study evaluated the relationship of circulating leptin concentration with exercise ventilation in HF patients. Methods and ResultsFifty-eight consecutive ambulatory HF patients were stratified by quintiles of leptin concentration, with a lowest quintile of mean leptin concentration of 1.8 ± 8.9 ng/mL and a highest of 33.3 ± 30.3 ng/mL. Peak exercise ventilatory efficiency (VE/VCO2) was significantly elevated in the lowest (46 ± 6 vs 34 ± 4; P < .01) as well as in the highest (38 ± 8 vs 34 ± 4; P < .05) leptin concentration quintiles compared with the reference middle quintile. Multiple regression analysis adjusted for confounders such as age, sex, and body mass index showed leptin concentration to be independently inversely correlated to VE/VCO2 in the low-to-normal quintiles (β = −0.64; P < .01), positively in the normal-to-high quintiles (β = 0.52; P = .02), and positively correlated to PETCO2 in the low-to-normal quintiles (β = 0.59; P = .01) and inversely in the normal-to-high quintiles (β = −0.53; P = .02). ConclusionsIn HF patients, both high and low leptin concentrations are associated with increased VE/VCO2 and decreased PETCO2 with a nonlinear U-shaped relationship, suggesting that either leptin deficiency or leptin resistance may modulate ventilatory control in HF patients.

Atrial fibrillation and heart failure

Atrial fibrillation and heart failure are two of the most prevalent cardiovascular disease conditions. They often coexist and lead to significant morbidity and mortality. Adequate management strategies for this dual epidemic continue to be the subject of many research studies. Recent clinical trials suggest that a rhythm control strategy for atrial fibrillation does not offer a survival advantage over rate control in heart failure patients with reduced systolic function. Rhythm control in these trials was achieved using antiarrhythmic drugs, with evidence of increased mortality associated with certain agents. Catheter ablation is a more effective and increasingly used approach to maintain sinus rhythm in atrial fibrillation patients, with promising results in the heart failure population. Late-gadolinium-enhancement cardiac MRI (LGE-MRI) assessment of atrial fibrosis helps in selecting the better candidates for atrial fibrillation ablation. AV nodal ablation and bi-ventricular pacing remains another viable option. Atrial fibrillation patients with heart failure and preserved systolic function are another group in whom maintenance of sinus rhythm is thought to be advantageous. Patients with atrial fibrillation and heart failure are a heterogeneous group and require a personalized treatment approach. Catheter ablation to restore and maintain sinus rhythm is a modality that promises to be advantageous beyond rate control.

Functional electrical stimulation for chronic heart failure: A meta-analysis

IntroductionWe conducted a meta-analysis of randomized, controlled trials of combined electrical stimulation versus conventional exercise training or placebo control in heart failure patients. MethodsA systematic search was conducted of Medline (Ovid) (1950–September 2011), Embase.com (1974–September 2011), Cochrane Central Register of Controlled Trials and CINAHL (1981–September 2011). The search strategy included a mix of MeSH and free text terms for the key concepts heart failure, exercise training and functional electrical stimulation (FES). ResultsFES produced inferior improvements in peak VO2 when compared to cycle training: mean difference (MD) −0.32ml.kg−1.min−1 (95% C.I. −0.63 to −0.02ml.kg−1.min−1, p=0.04), however FES elicited superior improvements in peak VO2: MD 2.30ml.kg−1.min−1 (95% C.I. 1.98 to 2.62ml.kg−1.min−1, p<0.00001); and six minute walk distance to sedentary care or sham FES; MD 46.9m (95% C.I. 22.5 to 71.3m, p=0.0002). There was no difference in change in quality of life between cycling and FES, but FES elicited significantly larger improvements in Minnesota Living with Heart Failure score than placebo or sham treatment; MD 1.15 (95% C.I. 0.69 to 1.61, p<0.00001). Moreover, the total FES intervention hours were strongly correlated with change in peak VO2, (r=0.80, p=0.02). ConclusionsPassive or active exercise is beneficial for patients with moderate to severe heart failure, but active cycling, or other aerobic/resistance activity is preferred in patients with heart failure who are able to exercise, and FES is the preferred modality in those unable to actively exercise. The benefits of FES may however, be smaller than those observed in conventional exercise training. Aggregate hours of electrical stimulation therapy were associated with larger improvements in cardio-respiratory fitness.

Antibodies to Oxidized LDL as Predictors of Morbidity and Mortality in Patients With Chronic Heart Failure

Background Oxidative stress appears to play a significant role in the pathogenesis of heart failure (HF). Antibodies to oxidized low-density lipoprotein (Ox LDL Abs) reflect an immune response to LDL over a prolonged period and may thus represent oxidative stress over an extended time. Ox LDL Abs have been shown to correlate with clinical control in HF patients. We evaluated the predictive power of Ox LDL Abs on the outcome in patients with HF. Methods and Results Baseline levels of Ox LDL Abs were determined by enzyme-linked immunosorbent assay in 284 consecutive outpatients with severe chronic HF who were being treated in the cardiology services of our medical center. Their mean New York Heart Association (NYHA) Class was 2.8. The mean follow-up for the group was 3.7 years, during which 107 (37%) died. The mean time from symptom onset to first hospital admission from HF was 25.8 months. Ox LDL Abs were found to predict morbidity and mortality as evaluated by a Cox multivariate regression analysis with a hazard ration of 1.013 ( P < .013), whereas N-terminal pro-B-type natriuretic peptide (NT pro-BNP) levels achieved a HR of 1.028 ( P < .099). Conclusions Ox LDL Abs level maybe a useful parameter for monitoring and planning better management of patients with HF. It was superior to pro-BNP as a predictor of clinical course as expressed by time to hospitalization.

Management of type 2 diabetes in patients with heart failure

Diabetes mellitus and heart failure (HF) commonly coexist, and together these conditions are associated with increased morbidity and mortality compared with either condition alone. Although the optimal treatment strategy to achieve glucose control in HF patients with type 2 diabetes has not been well studied, given the common coexistence of these conditions and the need to adequately treat hyperglycemia to prevent microvascular complications, it is important for clinicians to understand the potential implications of diabetic therapy in patients with established HF. Until recently, metformin was contraindicated in patients with HF because of the potential risk of lactic acidosis; however, recent retrospective studies of metformin use in HF patients have shown that this medication may be used safely and indeed may be beneficial in patients with stable HF. The association between thiazolidinediones (TZDs) and HF remains controversial, but recent prospective randomized trials of TZD use in HF patients suggest that worsening volume retention associated with these agents may lead to worsening of HF symptoms. The recently developed incretin-based therapies, such as exenatide and sitagliptin, also have not been extensively studied in HF populations; however, small pilot studies of glucagon-like peptide-1 have shown potential promise in the treatment of diabetic patients with HF. Although they may be difficult to perform, future randomized controlled trials are needed to establish optimal treatment goals and strategies in this population.

Effects of home‐based exercise training on neurovascular control in patients with heart failure

The effect of home-based exercise training on neurovascular control in heart failure patients is unknown. To test the hypothesis that home-based training would maintain the reduction in muscle sympathetic nerve activity (MSNA) and forearm vascular resistance (FVR) acquired after supervised training. Twenty-nine patients (54+/-1.9 years, EF<40%) were randomised into two groups: untrained control (n=12) and exercise trained (n=17). Both groups underwent assessment of Quality of Life (QoL), MSNA, and forearm blood flow. The exercise group underwent a 4-month supervised training program followed by 4 months of home-based training. After the initial 4 months of training, patients in the exercise group showed a significant increase in peak VO(2) and reduction in MSNA, compared to the untrained group, but this was not maintained during 4 months of home-based training. In contrast, the decrease in FVR (56+/-3 vs. 46+/-4 vs. 40+/-2 U, p=0.008) and the improvement in QOL that were achieved during supervised training were maintained during home-based training. Home-based training following supervised training is a safe strategy to maintain improvements in QoL and reduction in FVR in chronic heart failure patients, but is an inadequate strategy to maintain fitness as estimated by peak VO(2) or reduction in neurohumoral activation.

Effect of exercise training on weight control in patients with chronic heart failure

S44 Abstracts The Journal of Heart and Lung Transplantation February 2005 Conclusions: A significant increased risk of cardiovascular mortality was seen in heart transplant recipients with patterns of AMR or mixed rejection relative to those with a cellular rejection pattern, even when excluding deaths from acute rejection. With growing acceptance of AMR in heart transplantation by the ISHLT community, there is a greater need for standardized diagnostic criteria, prevention, and appropriate therapy. EFFECT OF EXERCISE TRAINING ON WEIGHT CONTROL IN PATIENTS WITH CHRONIC HEART FAILURE L.S. Evangelista, 1 K. Dracup, 2 L.V. Doering, 1 M.A. Hamilton, 3 School of Nursing, Univeristy of California Los Angeles, Los Angeles, CA; 2 School of Nursing, University of California San Francisco, San Francisco, CA; 3 Ahmanson Cardiomyopathy Center, UCLA Medical Center, Los Angeles, CA Exercise is an important behavior for long-term weight control in obese individuals. However, little evidence exists confirming such findings in chronic heart failure (HF) patients. Methods: Using a prospective, experimental design, we described the effects of 24 weeks of home-based walking program on weight control in obese (body mass index ⱖ25) HF patients randomized to exercise (n⫽48) and a control group (n⫽51). Weight changes between the 2 groups at baseline and 6 months were compared using repeated measures ANOVA. We compared patients who had lost, gained or had no weight changes over time using Chi-square statistics. Results: Demographic and clinical data were similar in the 2 groups at baseline. Patients who were in the exercise vs. control group demonstrated improvement in their weights from baseline to 6 months (Figures 1 and 2). Conclusion: Our findings demonstrate the beneficial effects of a home-based walking program on weight control in HF patients, suggesting that exercise produces physiological, behavioral, and psychological effects that may facilitate weight loss in this popu- lation. HOPING FOR THE BEST WHILE PREPARING FOR THE WORST: COMMUNICATION ABOUT END-OF-LIFE PLANNING IN HEART TRANSPLANT PROGRAMS J. Yager, 1 A. Hernandez, 1 J. Tulsky, 2 S. Russell, 3 1 Cardiology, Duke University Medical Center, Durham, NC; 2 General Medicine, Duke University Medical Center and VAMC, Durham, NC; 3 Cardiology, Johns Hopkins Hospital, Baltimore, MD Background: Up to 10% of adults awaiting heart transplantation die while on the waiting list (UNOS data), and another 10 –20% do not survive the first post-operative year. Given this context and recent guidelines recommending end of life (EOL) discussions with ad- vanced heart failure patients, we sought to describe the EOL planning and education that occur as part of the pre-transplant evaluation process. Methods: Transplant coordinators or program managers at high- volume adult U.S. transplant centers (defined as 20 or more in any of the last 3 years) were contacted by phone for a brief structured survey. We asked about EOL content in patient-provider discussions and in written material given to patients during the transplant evaluation process. Results: We identified 37 high-volume centers (performing approximately 60% of all adult US heart transplants) and 100% responded to the survey. 28 (76%) centers formally dis- cuss the fact that not all patients survive to transplant – cardiolo- gists do so at 19 centers, surgeons at 4, coordinators at 13, social workers at 7 and psychologists at 3 (some report multiple discus- sions). At 3 centers cardiologists discuss these issues only when deemed appropriate. During outpatient evaluations, 27 (73%) centers conduct advance directive (AD) planning, usually by a social worker (23 of 27). 6 (16%) offer AD planning only to inpatients. 12 (32%) centers provide generic written AD mate- rial to patients and only 4 (11%) include specific written EOL content. Conclusion: Most high-volume centers formally discuss the possibility of death pre-transplant, with large variability as to how it is presented. Fewer than half provide written AD or EOL material, and without this most patients probably do not retain much of the discussion. Efforts should be made to standardize the inclusion of EOL content in the pre-transplant evaluation process, and to measure the impact of sharing this information with patients.