Exacerbation Of Chronic Heart Failure Research Articles

Acute Decompensated Heart Failure: A Pharmacologic Review.

Chronic heart failure (CHF) is a growing disease in the United States. Exacerbations of CHF can lead to acute decompensated heart failure (ADHF) and hospitalizations. Nurses play a key role in the treatment of ADHF as they administer medications, monitor patients' response to therapy, and can prompt providers to alter therapy if therapeutic outcomes are not being achieved. Nurses also play a vital role in discharge education for patients who are hospitalized for ADHF, as they can counsel patients on ways to reduce further hospitalizations. It is important for nurses to understand and recognize symptoms of ADHF, pharmacologic treatments for ADHF, and common etiologies of ADHF to help improve patient outcomes.

Serum and Vascular Stiffness Biomarkers Associated with the Severity of Degenerative Aortic Valve Stenosis and Cardiovascular Outcomes.

Background: Although degenerative aortic valve stenosis (DAS) is the most prevalent growth-up congestive heart valve disease, still little known about relationships between DAS severity, vascular stiffness (VS), echocardiographic parameters, and serum biomarkers in patients undergoing transcatheter (TAVR) or surgical aortic valve replacement (SAVR). The objective of this study was to identify biomarkers associated with DAS severity, and those that are associated with cardiovascular death (CVD) and episodes of chronic heart failure (CHF) exacerbation. Methods: A total of 137 patients with initially moderate-to-severe DAS were prospectively evaluated for the relationship between DAS severity, baseline VS, and serum biomarkers (uPAR, GDF-15, Gal-3, IL-6Rα, ET-1, PCSK9, RANTES/CCL5, NT-proBNP, and hs-TnT), and were followed-up for 48 months. The prognostic significance of each variable for CVD and CHF risk was measured by hazard ratio of risk (HR), which was calculated by Cox’s proportional hazard model. Results: DAS severity showed correlations with IL-6Rα (r = 0.306, p < 0.001), uPAR (r = 0.184, p = 0.032), and NT-proBNP (r = −0.389, p < 0.001). Levels of ET-1 and Gal-3 were strongly correlated with VS parameters (r = 0.674, p < 0.001; r = 0.724, p < 0.001). Out of 137 patients, 20 were referred to TAVR, 88 to SAVR, and 29 to OMT. In TAVR patients, the highest levels of ET-1, Gal-3, and VS were found as compared to other patients. The highest incidence of CVD was observed in patients who underwent TAVR (35%), compared to SAVR (8%) and OMT (10.3%) (p = 0.004). In a multivariate analysis, ET-1 occurred predictive of CVD risk (HR 25.1, p = 0.047), while Gal-3 > 11.5 ng/mL increased the risk of CHF exacerbation episodes requiring hospital admission by 12%. Conclusions: Our study indicated that ET-1 and Gal-3 levels may be associated with the outcomes in patients with DAS.

P224 PRIMITIVE DILATED CARDIOMYOPATHY IN YOUNG MAN NOT ELIGIBLE FOR CARDIAC TRANSPLANTATION: COMBINED USE OF DEFIBRILLATOR, CARDIAC CONTRACTILITY MODULATION (CCM) AND CARILLON

Abstract Acute heart failure refers to rapid or gradual onset of symptoms and/or signs of chronic heart failure due to precipitating factors. Many patients with heart failure progress into a phase of advanced heart failure, characterized by persistent symptoms despite maximal therapy. Prognosis remains poor, with high 1–year mortality. Prognostic stratification is important to identify the ideal time for referral to an appropriate center capable of providing advanced therapies. We present the case of a 36–year–old black homeless man was admitted to Cardiological intensive care unit for acute heart failure complicated by intermediate–high risk bilateral subsegmentary pulmonary embolism, left endoventricular thrombosis, severe biventricular systolic dysfunction and secondary severe mitral insufficiency. After infusional diuretic and anticoagulant therapy, coronary angiography was performed documenting non–obstructive epicardial coronary arteries. Thereafter the therapy with sacubitril/Valsartan was falled, due to marked hypotension. Due to the high risk of sudden cardiac death, a single–chamber ICD was implanted in primary prevention. He was not eligible for long–term mechanical assistance (VAD) implantation and/or heart transplantation from referral centers, because of the patient‘s precarious psychosocial background. Furthermore, in the fullness of his faculties, the patient refused this possibility for religious reasons. Discharged in fair compensation, after resolution of pulmonary embolism and intracavitary thrombosis, he was again hospitalized for an exacerbation of chronic heart failure. Once labile hemodynamic compensation was reached, a cardiac contractility modulation device (CCM) was positioned, with the aim of improving symptoms. After optimization of therapy, with persistence of severe symptoms despite optimal medical and device therapy, options for intervention on the mitral valve were evaluated before further deterioration of the clinical conditions. Since this is a highly symptomatic patient at high risk for surgery, we opted for a coronary sinus mitral annuloplasty repair with Carillon, performed in the absence of complications. At the follow–up there was a mitral regurgitant volume reduction, improvement symptoms, in the absence of further hospitalizations.

Development and Validation of a Risk Score in Chinese Patients With Chronic Heart Failure

BackgroundAcute exacerbation of chronic heart failure contributes to substantial increases in major adverse cardiovascular events (MACE). The study developed a risk score to evaluate the severity of heart failure which was related to the risk of MACE.MethodsThis single-center retrospective observational study included 5,777 patients with heart failure. A credible random split-sample method was used to divide data into training and validation dataset (split ratio = 0.7:0.3). Least absolute shrinkage and selection operator (Lasso) logistic regression was applied to select predictors and develop the risk score to predict the severity category of heart failure. Receiver operating characteristic (ROC) curves, and calibration curves were used to assess the model’s discrimination and accuracy.ResultsBody-mass index (BMI), ejection fraction (EF), serum creatinine, hemoglobin, C-reactive protein (CRP), and neutrophil lymphocyte ratio (NLR) were identified as predictors and assembled into the risk score (P < 0.05), which showed good discrimination with AUC in the training dataset (0.770, 95% CI:0.746–0.794) and validation dataset (0.756, 95% CI:0.717–0.795) and was well calibrated in both datasets (all P > 0.05). As the severity of heart failure worsened according to risk score, the incidence of MACE, length of hospital stay, and treatment cost increased (P < 0.001).ConclusionA risk score incorporating BMI, EF, serum creatinine, hemoglobin, CRP, and NLR, was developed and validated. It effectively evaluated individuals’ severity classification of heart failure, closely related to MACE.

A Closer Look At Chronic Heart Failure Patients During The Covid-19 Pandemic

IntroductionDuring the early peak of the COVID-19 pandemic, several measures were instituted to reduce the risk of exposure among patients to the novel SARS-CoV-2 virus, including the implementation of a virtual healthcare encounter system. Unfortunately, this resulted in considerable interruptions in the dispensation of healthcare services to chronically ill patients, particularly among patients with chronic heart failure (CHF).HypothesisWe aim to study whether the patients who presented to the Kings County Hospital Emergency Department (KCH ED) with symptoms of CHF exacerbation in the months following the COVID-19 pandemic peak in New York City were impacted due to the interruption in their regular cardiology outpatient clinic visits.MethodsThe COVID-CHF study is a single-center, retrospective study of patients with CHF that presented to the KCH ED between 05/01/2020 - 12/31/2020 with CHF exacerbation symptoms, selected utilizing ICD-10 codes for admission diagnoses. Continuous variables are reported as mean ± standard deviations or median (interquartile range), while categorical variables are presented as numbers with frequencies. All analyses were performed on Microsoft Excel and R software.ResultsA total of 268 patients were included in our study, with the mean age 65.7±13.8 years and 45% female. The burden of comorbidities was high, with >50% of patients having hypertension, diabetes mellitus, and chronic kidney disease. Of the total patient population, only 61 (22.8%) patients attended a televisit appointment during the preceding pandemic months. At ED presentation, the primary presenting symptom was shortness of breath (86%), and the average hospital stay per visit was 3 (2-6) days. The projected mortality risk, according to the MAGGIC score, was 16 ± 10% at 1 year and 35 ± 17% at 3 years for our patient population. Although the gap between clinic visits and ER visits did not increase the mortality risk, patients presenting with worse New York Heart Association (NYHA) class symptoms had higher mortality risk (Figure). At discharge, 82% of patients were prescribed diuretics and 81% beta-blockers. Two patients died during admission and 3 patients died after discharge.ConclusionsIn our study, we noticed that despite the implementation of a virtual healthcare system during the COVID-19 pandemic, less than one-fourth of CHF patients were able to utilize it, and consequently, there was an increase in ED visits for acute CHF exacerbations in the ensuing months. Additionally, a worse grade of presenting symptoms was associated with higher mortality risk. Key Words: COVID-19, Heart Failure, Virtual Health

ИНГИБИРОВАНИЕ НАТРИЙ-ГЛЮКОЗНОГО ТРАНСПОРТНОГО БЕЛКА 2: КЛИНИЧЕСКИЕ И ФАРМАКОЛОГИЧЕСКИЕ ЭФФЕКТЫ ПРИ ХРОНИЧЕСКОЙ СЕРДЕЧНОЙ НЕДОСТАТОЧНОСТИ

Introduction. This article provides information of sodium-glucose co-transporter-2. Aim. The aim of the study was to review the current information on the positive effect of drugs from the sodium-glucose co-transporter-2 on the cardiovascular system of patients with chronic heart failure. Material and methods. A review of current published studies of sodium-glucose co-transporter-2 is provided. Results and discussion. In 2015, for the first time, there was a mention of the positive effect of sodium-glucose co-transporter-2 on the cardiovascular system of patients with type 2 diabetes mellitus. There was a decrease in the risk of death from cardiovascular diseases, non-fatal myocardial infarction, acute cerebrovascular accident, as well as a decrease in the frequency of hospitalizations for exacerbation of chronic heart failure. In 2020, information was obtained on the isolated effect of this group on chronic heart failure, regardless of the presence of type 2 diabetes. When studying the drugs, it was found that their cardioprotective effect is due to a decrease in blood pressure by increasing osmotic diuresis, partial suppression of the activity of the renin- angiotensin-aldosterone system due to an increase in sodium concentration in the area of the dense spot of the distal convoluted tubule, increased oxygen delivery to the heart muscle by stimulating erythropoiesis. Conclusion. It is reasonable to use drugs that belong to the group of inhibitors of sodium-glucose co-transporter-2 in clinical practice for the treatment of patients with chronic heart failure, regardless of whether they have type 2 diabetes mellitus.

Efficacy of trimetazidine - an inhibitor of free fatty acids oxidation in the treatment of patients with stable angina pectoris and heart failure.

Aim To evaluate efficacy of modified-release trimetazidine (TMZ) included into the standard therapy for patients with stable angina and chronic heart failure (CHF) as a part of a subgroup analysis in the PERSPECTIVE study.Material and methods The study included 806 patients: group 1 (n=691), patients receiving a standard therapy and modified-release TMZ (TMZ group); and group 2 (n=115), patients receiving a standard therapy (control group). Total duration of the study was 12 months.Results In the TMZ group, the weekly number of angina attacks decreased by 41.9% (p&lt;0.0001) in 2 months and by 69.6 % (from baseline, р&lt;0.0001) in 12 months, and the frequency of nitroglycerine dosing decreased by 40.8 % (р&lt;0.0001) and 67.7 % (р&lt;0.0001), respectively. In the control group, the respective values did not change. In the TMZ group compared to the control group, the QT interval was shorter (7.9 %; р&lt;0.05), the left ventricular (LV) end-systolic dimension was reduced (13.4 %; р&lt;0.01), interventricular septal thickness and LV posterior wall thickness were decreased (9.5 %; р&lt;0.01 and 12.2 %; р&lt;0.01, respectively), and the ejection fraction was increased (11.4; р&lt;0.05). Following the TMZ treatment, the leukocyte count in peripheral blood was decreased (5.3 %; р&lt;0.01) and the serum concentration of high-sensitivity C-reactive protein was decreased (30.7 %; р&lt;0.01) vs. increases of these indexes in the control group (17.9 %; р&lt;0.05 and 17.8 %; р&lt;0.05, respectively). The proportion of patients hospitalized for exacerbation of CHF or angina for 12 months was 8.6 % in the TMZ group and 15.7 % in the control group (p=0,001).Conclusion In patients with stable angina and CHF, inclusion of modified-release TMZ into the standard therapy decreases the number of angina attacks, reduces the activity of inflammatory factors, and improves the course of disease.

Abstract 11234: The Impact of Median Yearly Income on Structural Heart Disease Procedural Outcomes

Introduction: The association of socioeconomic status with health outcomes is well known. This study used zip codes as a surrogate for income and compared outcomes post-procedure and at 6 and 12 months following TAVR at an urban hospital. Methods: We performed a retrospective study on patients undergoing TAVR at the University of Illinois-Chicago(UIC) in Chicago, Illinois between March 2018 and June 2020. Using income data from the US Census Bureau, patients were placed into 2 groups: zip codes with a median income less than the national urban mean income of $54,296 (LMI) and greater than the average urban mean yearly income (GMI).Primary outcomes included composite MACE (CV death, MI and/or CVA), length of stay, and all-cause death. Secondary outcomes included CHF exacerbation, and repeat revascularization. Outcomes were analyzed at hospital discharge, 6 months and 12 months. T and Chi square tests were used to analyze continuous/categorical variables, respectively. Results: We analyzed 114 patients, 84 patients were categorized as LMI and 30 patients were categorized as GMI. 94.3% of the LMI group was Black, while only 62% of the GMI group was Black. Age and gender distributions were similar between groups. Initial post procedural outcomes showed no statistical difference between the LMI and GMI. The LMI group trended towards a longer length of stay than the GMI group (p=0.1). A history of heart failure was greater in the LMI group (p = 0.025). At 6 months there was a lower repeat revascularization rate in the LMI group compared to the GMI group (0% vs. 1.8%, p = 0.017). However, other outcomes including composite MACE (9.6% vs. 1.8%, p=0.3) and all cause death (6.1% vs. 0.9%p=0.4) were statistically similar. At 12 months only 112 patients had recorded outcomes. At this time, repeat revascularization was still significantly different (0% vs. 2.6%, p = 0.005) but all other outcomes remained nonsignificant. Results: Post TAVR, patients in the GMI group experienced a higher rate of repeat coronary revascularization as compared to the LMI group, although, the composite event rate was similar. Further investigation into this observation is warranted; however, overall outcomes between patients from poorer communities seems to be similar to wealthier communities.

Clinical effects of the enhanced external counterpulsation therapy in patients with ischemic chronic heart failure exacerbation COVID-19

Abstract Objectives The aim of the study was to assess the effects of the enhanced external counterpulsation (EECP) therapy as a rehabilitation method in patients with ischemic chronic heart failure (CHF) after COVID-19. Methods 54 (n=54) stable symptomatic CHF (NYHA, functional class I-II; 35%≤LVEF≤50%) subjects (44 male and 10 female; mean age 61±9,8) with prior anamnesis of CAD, at least one myocardial infarction got the exacerbation of CHF after COVID-19 episode. They were randomized in a 2:1 manner into either 35 1-hour 250–300 mm Hg sessions of EECP (n=36; 30 male, 6 female) or Sham-EECP (n=18; 14 male, 4 female). All subjects had been received optimal CHF and CAD drug therapy. At baseline, a month and half a year after EECP course every subject was examined with echocardiography and 6-minute walk test. Results All 36 active EECP treatment group subjects improved by at least 1 NYHA class, 66% of them had no heart failure symptoms post treatment (p&amp;lt;0.01). 84% of treatment group pts. had sustained NYHA class improvement at half a year follow-up (p&amp;lt;0.01), compared with baseline. There was significant difference between LVEF 44±6,5% at baseline vs post-EECP LVEF 50±4,6% (p&amp;lt;0.01) in active EECP treatment group subjects. At the same time there were no significant changes of NYHA class and LVEF in Sham-EECP subjects. No one subject dies after half a year of follow up. Conclusions Enhanced external counterpulsation (EECP) therapy sustainably improves NYHA functional class and LVEF in patients with ischemic CHF exacerbation after COVID-19. Funding Acknowledgement Type of funding sources: None.

Polymorphism of the ITGAM gene (rs7193943) and bioelectric impedance analysis as potential predictors of cachexia in chronic heart failure

Cardiac cachexia (CC) is an unfavorable metabolic syndrome leading to exacerbation of chronic heart failure (CHF) and a higher risk of death. The main factor contributing to the development of cachexia is the ongoing inflammatory process mediated by genes (e.g. Integrin Subunit Alpha M—ITGAM). The study aimed to assess the relationship between a single nucleotide polymorphism (SNP) -323G > A of the ITGAM and the occurrence of nutritional disorders in patients with CHF. 157 CHF patients underwent clinical and nutritional screening. Body composition was evaluated by bioelectrical impedance analysis (BIA). Patients with cachexia were characterized by significantly lower weight, body mass index (BMI), lower fat mass (FM), albumin, and hemoglobin. Lower values of BIA parameters: capacitance of membrane (Cm), phase angle (PA), and impedance ratio (Z200/Z5) were noted in women. Those patients demonstrated significantly higher values of creatinine, c-reactive protein (CRP), N-terminal prohormone of brain natriuretic peptide (NT-proBNP), and pulmonary artery systolic pressure (PASP). A significantly higher risk of cachexia was reported in patients: aged ≥ 74 years (OR 3.55), with renal failure (OR 3.75), New York Heart Association classification (NYHA) III-IV (OR 2.83), with moderate or severe malnutrition according to the score of subjective global assessment (SGA) (OR 19.01) and AA genotype of ITGAM gene (OR 2.03). Determination of the -323G > A SNP in the ITGAM may prove to be a useful marker (after confirmation in further studies and appropriate validation) in the assessment of the risk of nutritional disorders in patients with CHF.

MANUBRIOSTERNAL JOINT SEPTIC ARTHRITIS IN A MAN WITH A HISTORY OF IV DRUG USE

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: Septic arthritis is a well-documented disease, much of which contains specific guidelines and recommendations for management. Manubriosternal joint septic arthritis is a rare entity described in literature that lacks consistently successful treatment options. (1) We present the case of a patient found to have a tender chest wall mass and imaging concerns for manubriosternal septic arthritis. CASE PRESENTATION: A 47-year-old male with history of heart failure with reduced ejection fraction, drug-induced non-ischemic cardiomyopathy, cirrhosis, and history of intravenous drug use was admitted to the hospital from heart failure clinic for acute on chronic heart failure exacerbation and mild encephalopathy. He was afebrile but tachycardic with a leukocytosis (13 k/ul) upon presentation. During examination a tender, fluctuant mass was discovered over the sternum. He reported pain in this area began three weeks prior with a mass developing over the previous one week. Chest roentgenogram showed an enlarged cardiac silhouette. Follow-up chest computed tomography revealed a 5 cm x 6 cm mass containing gas surrounding the manubriosternal joint anteriorly and posteriorly. He underwent incision and drainage by cardiothoracic surgery where purulent material was found and appeared to connected to the posterior sternal fluid collection. Wound culture grew Streptococcus agalactiae. Sternal bone biopsy was negative for osteomyelitis. He was placed on IV penicillin G for four weeks of therapy. DISCUSSION: Primary manubriosternal joint infections have been rarely documented in literature with approximately 20 (adult and pediatric) cases noted in a PubMed literature search. (1) Cases appear to be more common in men approaching middle-age. Predisposing risk factors are often present and similar to those for septic arthritis of more typical joint locations including intravenous drug use, immunosuppression, and secondary sources of infection. (1,2,3) Specific treatment guidelines are not clearly defined in literature, likely due to the rarity of this disease process. (1) Various treatment methods have been reported which include various combinations of IV antibiotics, incision and drainage, and aggressive manubriosternal joint resection. (1,2,3) The most common treatment noted during the literature review was conservative management with IV antibiotics. CONCLUSIONS: Manubriosternal joint infections are infrequently seen. A majority of cases reported have presented with typical risk factors for septic arthritis. Consistent treatment guidelines are not available due to the rarity of this disease process though many are treated conservatively with IV antibiotics. Patients should be evaluated by a multidisciplinary team of cardiothoracic surgeons and infectious disease specialists for patient-centered decision making efforts. REFERENCE #1: Ali B, Shetty A, Borah G, Demas C, Schwartz JD. Successful management of sternomanubrial joint septic arthritis with pectoralis muscle flap closure: a case series. J Surg Case Rep. 2020;2020(4):rjaa035. Published 2020 Apr 29. REFERENCE #2: Peng EW, McKillop G, Prasad S, Walker WS. Septic arthritis of the manubriosternal joint. Ann Thorac Surg. 2007;83(3):1190-1194. REFERENCE #3: Carnevale A, Righi R, Maniscalco P, et al. Primary septic arthritis of the manubriosternal joint in an immunocompetent young patient: A case report. Radiol Case Rep. 2017;12(4):682-685. Published 2017 Sep 11. DISCLOSURES: No relevant relationships by Joseph Frederickson, source=Web Response No relevant relationships by Bryton Perman, source=Web Response no disclosure on file for Akshat Sood; No relevant relationships by David Wessling, source=Web Response

Cost-effectiveness of levosimendan in patients with exacerbation of chronic heart failure — a single-center perspective

Introduction: Heart failure (HF) places a significant economic burden on the health care system all over the world mainly due to frequent and repetitive hospitalizations. Thus, there is a need for both cost-effective and efficient therapeutic options. The aim of the study was to describe the economic aspect of levosimendan treatment in hospitalized HF patients in one major Polish cardiology unit. Material and methods: Retrospective observational study included 1086 patients with exacerbation of chronic HF, admitted to the Cardiology Department, University Hospital No 1 in Bydgoszcz, Poland in 2018–2020. We analyzed the cost of therapy, cost and the length of stay of 1057 hospitalizations of patients receiving standard therapy (ST) only and 29 hospitalizations of patients receiving levosimendan (Levo) on top. Levosimendan was used in patients not responding to standard therapy, mostly as a drug of the last chance. Results: The mean length of hospital stay for the ST patients was 9.4 days compared to 29.1 days for the Levo group. The median total cost of hospitalization of patients receiving ST was significantly lower compared to Levo group [PLN 6,612.5 (IQR 3,624.9—13,301.3) vs PLN 23,854.9 (IQR 10,900.4–40,391.5), p < 0.001]. On the other hand, the median daily cost of hospitalization did not differ between the ST and Levo group [PLN 772 (616.4–1,629) vs PLN 1,010.5 (IQR 787.4–1,172), p = 0.1]. The total cost of treatment was significantly lower only in the ST subgroup hospitalized for less than 2 weeks compared to the Levo group (p = 0.008). An early decision of levosimendan introduction (up to 8 days) resulted in a shorter hospitalization time compared to later drug administration (21 days vs 42 days; p = 0.019). Conclusions: Early administered levosimendan in HF exacerbation seems to be cost-effective in Polish clinical and economic settings. Despite the high cost of drug acquisition, it may provide better outcomes at lower overall costs of HF patient management. A randomized trial will be necessary to address this issue in Poland.

Using “Big-Data” to Evaluate in-Hospital Morbidity and Mortality in Systemic Light Chain (AL) Amyloidosis after High Dose Therapy and Autologous Stem Cell Transplant (HDT/ASCT)

Background: HDT/ASCT can provide a deep hematological response and result in improvement of amyloid related organ dysfunction in a selected group of AL amyloidosis patients (pts.), but is confounded by substantial treatment-related mortality (TRM) compared to multiple myeloma (MM). However, recent trends have shown improved outcomes of HDT/ASCT in experienced US transplant centers with 30-day mortality of 3%. We performed an analysis of the Nationwide Inpatient Sample (NIS) to compare and better delinate the immediate in-hospital complications and mortality in AL amyloidosis and MM pts. post HDT/ASCT.Methods: The NIS is a large inpatient healthcare database in the US. Unweighted, it contains data from >7 million hospital stays each year and weighted, it estimates >35 million hospitalizations. Full-year data was available for 2008-2013, and this study period was queried to identify patients >18 years of age with a discharge diagnosis of AL amyloidosis and MM after HDT/ASCT conducting a survey weighted domain analysis. Clinical characteristics and in-hospital complications were compared between the two groups using ANOVA test for continuous variables and chi-square tests for categorical variables. Multiple logistic regression was used to compare binary outcomes by AL amyloidosis and MM pts. adjusting for patient characteristics (age, sex, Charlson Co-morbidity Index; CCI).Results: A total of 329 AL amyloidosis pts. were admitted for HDT/ASCT compared to 5302 MM pts. over the 6 year period. The baseline demographics were comparable between the two groups with the exception of CCI (Table 1). Compared to MM, AL amyloidosis pts. were significantly more likely to develop CHF exacerbation (OR 2.69 (95% CI (1.72,4.22); p<0.001); acute renal failure (OR 1.93; 95% CI (1.41,2.66); p<0.001); cardiac arrhythmias (OR 2.19; 95% CI (1.49,3.23); p<0.001); and septic shock (OR 2.14; 95% CI (1.13,4.05); p=0.02); but less likely to develop mucositis (OR 0.56; (95% CI (0.42,0.74); p<0.001) and febrile neutropenia (OR 0.72; (95% CI (0.57,0.91); p=0.005). There was no difference in the use of parenteral nutrition, mechanical ventilation, sepsis and hemodialysis between the groups. Overall, in-hospital mortality in AL amyloidosis pts. was 2.8% compared to 1.3% in MM (p=0.006). On adjusted analysis, there was no difference in in-hospital mortality compared to MM pts. (OR 1.32; 95% CI (0.67, 2.60); p=0.41). The length of stay (LOS) was higher in AL amyloidosis pts. (Mean LOS 20.7 days± 1.01 vs. 17.6 ± 0.52 days; p<0.001) and had higher total hospital charges (mean 185, 000 USD ± 5660 vs. 158,000 ± 8660 p<0.001) compared to MM pts.Conclusions: The results of our large US-population based study showed that AL amyloidosis pts. undergoing HDT/ASCT had increased rates of cardiac and renal complications, higher LOS and total hospital charges immediate post HDT/ASCT compared to MM cohorts. Despite this, there was no difference in adjusted in-hospital mortality between the two groups, underscoring the ever-improving quality of supportive care, better patient selection and effective drugs in treating these pts. This data may help guide informed consent discussions while providing focus for future studies to reduce treatment-related morbidity in AL amyloidosis pts. receiving HDT/ASCT. [Display omitted] DisclosuresDhakal:Celgene: Honoraria. Guru Murthy:Janssen: Other: Fellows advisory board. D'Souza:Prothena: Research Funding; Merck: Research Funding; Celgene: Consultancy. Hari:Celgene: Consultancy, Honoraria, Research Funding.

Dialysis Disequilibrium Syndrome in a Patient With Acute Kidney Injury on Chronic Kidney Disease

Dialysis disequilibrium syndrome (DDS) is a neurological complication that has been known to occur after hemodialysis (HD). In recent years, the prevalence of DDS has been low as the symptoms are widely recognized; hence, preventive therapies, such as the slow and gentle procedure for HD, are often administered before starting dialysis. However, once DDS occurs, it may cause seizures, coma, and even death in severe cases. Since there has been no established treatment, recognizing risk factors and preventing the syndrome is important.A 76-year-old man was admitted to our hospital due to exacerbation of chronic heart failure. He also had a history of chronic kidney disease and had consulted with his home doctor about the preparation for HD a month before admission. After treatment with diuretics, the symptoms ameliorated, but he experienced presyncope and malaise. Laboratory tests revealed acute anemia and a decrease in renal function. Upper gastrointestinal endoscopy revealed active bleeding from a gastric ulcer, which was successfully stopped. However, his consciousness deteriorated because of uremia; hence, HD was initiated. We used a cellulose triacetate membrane with a surface area of 1.3 m2 and maintained a dialysate flow rate of 500 ml/min with a blood flow rate of 120 ml/min. Four hours after starting HD, he suddenly developed generalized tonic convulsions. The dialysis was immediately stopped, and the patient was transferred to an intensive care unit. A computed tomography scan of the head showed mild edematous change of the brain, and laboratory tests also revealed a rapid decrease of urea nitrogen. We rationalized that he might have developed DDS. After injection of levetiracetam for the treatment of seizures, we initiated continuous hemodiafiltration as renal replacement therapy. Fortunately, his consciousness gradually improved, and he was completely alert on day 18 after admission.With reference to our current report, DDS can occur even following acute kidney injury, as the progression rate of the injury and accumulation of blood urea may not correlate with the risk of the syndrome.

P018. Case Study of Heart Failure Exacerbation Management via Tele-Health

<h3>Background</h3> • 6.5 million American adults have heart failure • Advance Practice Providers (APP) can successfully manage CHF exacerbation via Tele-Health Case Study •HPI: 74-year-old male with a PMHx of ICM, HFrEF (EF 25-30%), HTN, HLD, obesity, OSA, hx of tobacco use and EtOH abuse. Cardiology consulted for worsening edema, weight gain, escalating SOB and DOE. • NP provided same day Tele-Health visit and diagnosed patient with CHF exacerbation. Treatment plan in alignment with Goal Direct Medical Therapy (GDMT) developed for inpatient diuresis. NP adapted plan for outpatient setting after patient refused admission citing concern for COVID-19. • Patient educated and performed in-home self-monitoring of weight and BP. Labs drawn in outpatient clinic. • NP tailored & provided close patient monitoring via weekly Tele-visits for 6-8 weeks thereafter bi-weekly visits and one F2F visit bundled with echocardiogram, additional PRN visits provided for symptomatic changes. <h3>Results</h3> Patient presented weighing 209lbs, diuresis to 180.8lbs (-28.2lbs) over 2 months. BNP decreased from 2534 to 496. <b>Labs:</b> Stable electrolytes/renal panel (K+4.2-4.9, Cr 0.99-1.21) throughout care. <b>QoL:</b> Minimal symptoms, no longer sleeping in recliner and improved energy level. <b>Plan:</b> Continue bi-weekly and PRN phone visits. Continue GDMT. Refers to cardiac catheterization and device/clinic for ICD/defibrillator evaluation. <h3>Conclusions</h3> This case occurred during the COVID-19 pandemic. The NP successfully provided outpatient management of a CHF exacerbation in accordance to GDMT via Tele-Health visits. To date patient is without hospitalization and symptomatically markedly improved. Overall optimizing patient safety, autonomy, and cost savings related to hospitalization.

Fibrinogen Level Predicts Outcomes in Critically Ill Patients with Acute Exacerbation of Chronic Heart Failure.

Background Heart failure (HF) is a common cardiovascular disease, which is related to systemic inflammation for decades. Fibrinogen (FIB) is a sign of thrombosis and inflammation, which is associated with the prognosis of many diseases. Nevertheless, the role of fibrinogen level in the prognosis of critically ill patients with acute exacerbation of chronic heart failure is unclear. Methods The data are from the Medical Information Mart for Intensive Care III (MIMIC III) database, which is a freely accessible critical care database. The primary outcome in our study was 90-day mortality. The prognostic value of fibrinogen was analyzed with receiver operating characteristic (ROC) curve analysis, Kaplan-Meier curve, and Cox model. Results A total of 554 patients were included. Patients were divided into two groups, low fibrinogen level (<284 mg/dl) and high fibrinogen level (≥284 mg/dl), through the cut-off value of the ROC curve. The area under the ROC curve of fibrinogen for predicting 90-day mortality was 0.65 (95% CI: 0.59–0.70). In the unadjusted Cox model, compared with the low fibrinogen level (<284 mg/dl), the 90-day mortality of the hazard ratio (HR) with 95% confidence intervals (CI) of the high fibrinogen level is 3.33 (95% CI 2.15-5.15). In different multivariable Cox models, compared with the low fibrinogen level (<284 mg/dl), the 90-day mortality of the hazard ratio of the high fibrinogen level is from 2.83 to 3.13. In subgroup analyses, significant interactions were observed only in age, chronic kidney disease (CKD), and APS III scores. Conclusion Our data suggest that high fibrinogen levels (≥284 mg/dl) independently predict mortality in critically ill patients with acute exacerbation of chronic heart failure. Our findings need to be further validated by large prospective studies and longer follow-up time.

Combination therapy of midodrine and droxidopa for refractory hypotension in heart failure with preserved ejection fraction per a pharmacist\u2019s proposal: a case report

BackgroundPatients with chronic heart failure (CHF) are often treated using many diuretics for symptom relief; however, diuretic use may have to continue despite hypotension development in these patients. Here, we present a case of heart failure with preserved ejection fraction (HFpEF), which is defined as ejection fraction ≥50% in CHF, and refractory hypotension, which was treated with midodrine and droxidopa to normalize blood pressure.Case presentationThe patient was a 62-year-old man with a history of HFpEF due to mitral regurgitation and complaints of dyspnea on exertion. He had been prescribed multiple medications at an outpatient clinic for CHF management, including azosemide 60 mg/day, bisoprolol 2.5 mg/day, enalapril 2.5 mg/day, spironolactone 50 mg/day, and tolvaptan 15 mg/day. The systolic blood pressure (SBP) of the patient remained at 70–80 mmHg because the use of the diuretic could not be reduced or discontinued owing to edema and weight gain. He was hospitalized for the exacerbation of CHF. Although midodrine 8 mg/day was administered to improve hypotension, the SBP of the patient increased only up to 90 mmHg. On the 35th day after hospitalization, the urine volume decreased significantly (< 100 mL/day) due to hypotension. When droxidopa 200 mg/day replaced intravenous noradrenaline on the 47th day, the SBP remained at 100–120 mmHg and the urine volume increased.ConclusionsOral combination treatment with midodrine and droxidopa might contribute to the maintenance of blood pressure and diuretic activity in HFpEF patients with refractory hypotension. However, further long-term studies evaluating the safety and efficacy of this combination therapy for patients with HFpEF are needed.

The contribution of individual mental health and socioeconomic status to the evolution of elderly patients with chronic heart failure.

The purpose of this article is to assess the impact of comorbid depression on the outcome of elderly patients diagnosed with chronic heart failure (CHF). We conducted a prospective analysis of the outcomes of 251 patients, hospitalized throughout 2019 for an exacerbation of CHF. The sample was divided into two groups: group A - 153 patients with major depressive disorder (MDD); group B - 98 patients without clinical depression. We analyzed the associations between socioeconomic status (SES) and the severity of depressive symptoms, pharmacotherapy, readmission, and mortality rates within 30 days and at one year. We classified patients' SES according to residence, income, education level, and family support. Quality of Life (QL) total scores were also assessed. The severity of mental health complaints was evaluated using the Montgomery-Asberg Depression Ratings (MADRS) scale; individual somatic evaluation included the analysis of the alteration of the left ventricular ejection fraction (LVEF), as well as details regarding pharmacotherapy with angiotensin-converting enzyme (ACE) inhibitors and beta-blockers (BB). The patient sample appeared uniform in terms of SES and CHF pharmacotherapy. The main differences were the presence of comorbid MDD, with 60.91% of patients having clinical depression. These patients also reported a lower QL, reduced LVEF, more frequent, and extended hospitalizations with an overall higher one-year mortality than patients without MDD. Although depression is considered a risk factor for adverse outcomes in older adults with CHF, in our research, its impact was significantly associated with a reduced QL, but the association with a lower SES was inconclusive. MDD is a frequent comorbidity in patients with CHF, and is associated with a reduced LVEF and QL. Our results showed that, despite a similar therapeutic regimen, patients with comorbid MDD required more frequent, prolonged admissions and higher one-year mortality rates than those without MDD.

Association between fine particulate matter and heart failure hospitalizations: a time-series analysis in Yancheng, China.

Heart failure (HF) is a global public health problem of increasing importance. The association between acute exposure to air pollution and HF has been well established in developed countries, but little evidence is available in developing countries where air pollution levels are much higher. To explore the associations between PM2.5 and HF hospitalizations in Yancheng, China. In this time-series study, daily HF hospitalizations admitted in three major hospitals in Yancheng from May 1, 2015 to Apr 30, 2020 were collected. We used a generalized additive model with quasi-Poisson regression to investigate the association between PM2.5 and HF hospitalizations. The robustness of the associations was tested using two-pollutant models, and we examined the potential effect modification by age, gender, and season via stratification analyses. Lastly, we pooled the concentration-response curves. A total of 10,466 HF hospitalizations were recorded, with a daily average of 6 cases. We observed the most robust estimates on lag 0 day, and the associated increment in HF was 1.28% (95% CI 0.45%, 2.11%) for a 10-μg/m3 increase of PM2.5. The association remained after adjustment of O3, but not for NO2, CO, and SO2. The PM2.5-HF associations were positive in females, patients aged ≥ 65 years, and in cold season. The C-R relationship curve was generally increasing below 30 μg/m3. This study provided evidence on the association of PM2.5 with acute exacerbation of chronic heart failure, which may benefit future prevention strategy and policymaking.

Ivabradine prevents deleterious effects of dopamine therapy in heart failure: No role for HCN4 overexpression

BackgroundExacerbations of chronic heart failure (CHF) are often treated with catecholamines to provide short term inotropic support, but this strategy is associated with long-term detrimental hemodynamic effects and increased ventricular arrhythmias (VA), possibly related to increased heart rate (HR). We hypothesized that ivabradine may prevent adverse effects of short-term dopamine treatment in CHF. MethodsRats with post-myocardial infarction CHF received 2-week infusion of saline, dopamine(D), ivabradine(I) or D&I; cardiac function was assessed using echocardiography and pressure-volume loops while VA were assessed using telemetric ECG recording. Expression of HCN4, a potentially proarrhythmic channel blocked by ivabradine, was assessed in left ventricular (LV) myocardium. HCN4 expression was also assessed in human explanted normal and failing hearts and correlated with VA. FindingsDopamine infusion had detrimental effects on hemodynamic parameters and LV remodeling and induced VA in CHF rats, while ivabradine completely prevented these effects. CHF rats demonstrated HCN4 overexpression in LV myocardium, and ivabradine and, unexpectedly, dopamine prevented this. Failing human hearts also exhibited HCN4 overexpression in LV myocardium that was unrelated to patient’s sex, CHF etiology, VA severity or plasma NT-proBNP. InterpretationHR reduction offered by ivabradine may be a feasible strategy to extract benefits of inotropic support in CHF exacerbations, avoiding detrimental effects on CHF biology or VA. Ivabradine may offer additional beneficial effects in this setting, going beyond pure HR reduction, however prevention of ventricular HCN4 overexpression is unlikely to play a major role.