Goal-directed Medical Therapy Research Articles

Abstract 17470: Racial Disparities in Goal Directed Medical Therapy in Patients With Systolic Heart Failure- A Single Center Study

Introduction: Heart failure(HF) is a clinical syndrome that is widely prevalent affecting approximately 6.5 million people in the United States. It accounts for the ever-rising health care costs in the US due to recurrent hospitalizations. Despite advancements in medical management, the mortality and the rate of hospitalizations continues to be high with geographic variations and racial disparities. Through this descriptive study, we sought to analyze the health disparities among Hispanic, African American (AA) and Caucasian population in a single-center. Methods: We identified a total of 178 patients with HF with reduced ejection fraction from our outpatient clinic by utilizing the ICD-10 codes. Patients with ejection fraction >50% have been excluded. A retrospective chart review of their ethnic background, medications, and number of heart failure exacerbations per year has been performed. Results: 178 patients (mean age 62 years, 35.56% of females) including Hispanics (n=102), AA(n=44), and Caucasians (n=32) were included in the study. Although all patients were started on Beta-blockers, only 76.4% and 37.2% of Hispanics were started on ACEi/ARBs and spironolactone respectively. Similarly, 72.7% and 45.4% of AA were started on ACEi/ARBs and spironolactone respectively. This is in contrast to Caucasians population, where a majority of patients were on started on GDMT; 90% and 75% were started on ACEi/ARBs and spironolactone respectively. This was also reflected by the number of admissions due to HF exacerbations which ranged from 2-4/year for Hispanics and AA populations and 0-1/year for Caucasians. Conclusions: GDMT for HF is known to reduce heart failure exacerbations, mortality and the ever rising cost of the healthcare system. We have observed that despite recommendations to initiate GDMT in all patients with HF with reduced ejection fraction, racial disparities exist. Physicians should be mindful of initiating GDMT in all patients.

TAKOTSUBO CARDIOMYOPATHY SECONDARY TO ACUTE BACTERIAL MENINGITIS

SESSION TITLE: Medical Student/Resident Critical Care Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Infection and sepsis are not uncommon causes of cardiomyopathy due to a decrease in ventricular function. Cardiovascular dysfunction in sepsis can be seen as septic cardiomyopathy, Takotsubo cardiomyopathy, refractory shock or myocardial injury. A study showed that Takotsubo cardiomyopathy was present in 0.15% of admissions with severe sepsis. It should be considered in the differential diagnosis of acute coronary syndrome especially post-menopausal women with preceding stressful events. We present a case of bacterial meningitis leading to Takotsubo’s cardiomyopathy in the setting of CSF leak. CASE PRESENTATION: A 67-year-old woman with no past medical history presented to the emergency department with diarrhea, vomiting, and confusion. On arrival, she was hypotensive to 87/66mmHg, tachycardic 116bpm and hypoxic to 83% on room air. Laboratory evaluation was significant for leukocytosis of 29.2 k/ul, troponin 5.02 ng/ml, lactic acid 2.9 mmol/l, BNP 788 pg/ml. Cerebrospinal fluid showed a white blood cell count of 5011 (91% neutrophils), protein 791 mg/dl, glucose 95 mg/dl. She was admitted with a diagnosis of an NSTEMI, acute meningeal encephalitis and treated with aztreonam, vancomycin, doxycycline, and dexamethasone. Cultures revealed streptococcus viridians and treatment was narrowed to ceftriaxone. Facial CT showed a possible area of dehiscence concern for possible CSF leak. No significant coronary artery disease on the angiogram Echocardiogram was consistent with Takotsubo cardiomyopathy. The patient's cardiomyopathy was treated with goal-directed medical therapy with complete resolution of symptoms. DISCUSSION: Takotsubo cardiomyopathy is defined as a transient regional left ventricular systolic dysfunction without obstructive coronary artery disease and usually triggered by emotional or physical stress. During sepsis, there is an activation of the sympathoadrenergic system with rapid elevation in circulating catecholamine levels. Pathogenesis is related to myocardial stunning, catecholamine toxicity, impaired myocyte metabolism. According to Mayo Clinic criteria there should be: 1) transient hypokinetic, akinesias or dyskinesia of the LV midsegments, 2) absence of CAD, 3) EKG abnormalities or troponin elevation, 4) absence of pheochromocytoma or myocarditis. Patients can present with mild to moderate congestive heart failure or hypotension due to a reduction in stroke volume. The mean age of presentation ranges from around 60 to 75 years. The prognosis is excellent, mortality from 0%-8% and a recurrence occurs in <10% of patients. The treatment is based on the management of the underlying etiology and supportive cardiovascular care. CONCLUSIONS: Patients with suspected TTC need to be work up to rule out ACS with coronary angiogram. Takotsubo’s cardiomyopathy has a good prognosis with recovery on the EF and cardiac function once infection or physical stress disappears. Reference #1: De Giorgi, A., Fabbian, F., Pala, M., Parisi, C., Misurati, E., Molino, C., et al. (2015). Takotsubo Cardiomyopathy and Acute Infectious Diseases: A Mini-Review of Case Reports. Angiology, 66(3), 257–261. Reference #2: Pilgrim, TM, Wyss, TR. Takotsubo cardiomyopathy or transient left ventricular apical ballooning syndrome: a systematic review. Int J Cardiol. 2008;124(3):283–292. Reference #3: Prasad, A, Lerman, A, Rihal, CS. Apical ballooning syndrome (tako-tsubo or stress cardiomyopathy): a mimic of acute myocardial infarction. Am Heart J. 2008;155(3):408–417. DISCLOSURES: No relevant relationships by Daniel Colon Hidalgo, source=Web Response No relevant relationships by Diana Estefania Espinoza Barrera, source=Web Response No relevant relationships by Hugues Orozco, source=Web Response No relevant relationships by Jose Zabala-Genovez, source=Web Response

Myocardial Recovery in Dilated Cardiomyopathy with Goal Directed Medical Therapy

Background Dilated cardiomyopathy (DCM) is a common cause of heart failure (HF). Goal Directed Medical Therapy (GDMT) for HF has been shown to improve mortality and morbidity but rate of myocardial recovery is not well known. Methods In this retrospective study, 325 patients with newly diagnosed systolic heart failure (LVEF 10% and maintained >6 months. At baseline, all patients underwent echocardiogram; additionally, 22% underwent cardiac MRI, 7% cardiopulmonary stress test and 14% right heart catherization. GDMT was initiated inpatient and titrated weekly the first month, biweekly for the second month and monthly thereafter in our HF clinic. At discharge, 25% of the patients were sent home with wearable cardioverter-defibrillator (WCD). Results Of the 325 patients, 148 patients (45.5%) had myocardial recovery. In the recovery group, average age was 55.0 years, 58.8% were males, 64.9% Caucasians and 30.0% African Americans. At baseline, average LVEF was 27.3% and NYHA class 2.3. Average time for myocardial recovery was four months post initiation of GDMT. At one-year follow-up, average LVEF was 48.6% and NYHA class 1.7. In the recovery group, 84.0% were on ACEI/ARB/ARNI, 95.3% BB, 59.5% MRA, 4.7% Hydralazine, 2.7% Nitrates and 13.4% on Digoxin. No malignant arrhythmias were noted in patients discharged with WCD. The 30-day HF readmission rate in the myocardial recovery group was Conclusion GDMT for HF is well established and with aggressive medication titration in newly diagnosed systolic HF due to DCM and NICM, myocardial recovery is possible with rates as high as 45.5% at one-year.

Trends in peripheral arterial disease incidence and mortality in EU15+ countries 1990-2017.

The aim was to assess trends in peripheral arterial disease (PAD) incidence and mortality rates in European Union(15+) countries between 1990 and 2017. This observational study used data obtained from the 2017 Global Burden of Disease study. Age-standardised mortality and incidence rates from PAD were extracted from the Global Health Data Exchange for EU15+ countries for the years 1990-2017. Trends were analysed using Joinpoint regression analysis.Between 1990 and 2017, the incidence of PAD decreased in all 19 EU15+ countries for females, and in 18 of 19 countries for males. Increasing PAD incidence was observed only for males in the United States (+1.4%). In 2017, the highest incidence rates were observed in Denmark and the United States for males (213.6 and 202.3 per 100,000, respectively) and in the United States and Canada for females (194.8 and 171.1 per 100,000, respectively). There was a concomitant overall trend for increasing age-standardised mortality rates in all EU15+ countries for females, and in 16 of 19 EU15+ countries for males between 1990 and 2017. Italy (-25.1%), Portugal (-1.9%) and Sweden (-0.6%) were the only countries with reducing PAD mortality rates in males. The largest increases in mortality rates were observed in the United Kingdom (males +140.4%, females +158.0%) and the United States (males +125.7%, females +131.2%). We identify shifting burden of PAD in EU15+ countries, with increasing mortality rates despite reducing incidence. Strong evidence supports goal-directed medical therapy in reducing PAD mortality - population-wide strategies to improve compliance to optimal goal-directed medical therapy are warranted.

Reducing Readmissions for Heart Failure.

Reducing Readmissions for Heart Failure.

Trends in Peripheral Arterial Disease Incidence and Mortality in EU15+ Countries 1990-2017

Introduction: Ischaemic heart disease and cerebrovascular disease mortality rates have reduced over recent decades in Europe and the United States. We assessed whether mortality rates from peripheral arterial disease (PAD) - the third leading cause of atherosclerotic cardiovascular morbidity - showed similar trends. Methods: PAD age-standardised mortality and incidence rates were extracted from the Global Burden of Disease Study database for European Union(EU)15+ countries for the years 1990-2017. Annual mortality-to-incidence indices were calculated for each EU15+ country to provide a population based indicator of changes in disease burden. Results: Between 1990 and 2017, the incidence of PAD was observed to be down-trending in all 19 EU15+ countries for females, and in 18 of 19 countries for males: Increasing PAD incidence was observed only for males in the United States (+1.4%) (Figure 1). In 2017, the highest incidence rates were observed in Denmark and the United States for males (213.6 and 202.3 per 100,000, respectively) and in the United States and Canada for females (194.8 and 171.1 per 100,000, respectively). There was a concomitant overall trend for increasing age-standardised mortality rates in all EU15+ countries for females, and in 16 of 19 EU15+ countries for males over the same time period (Figure 2). Italy (-25.1%), Portugal (-1.9%) and Sweden (-0.6%) were the only countries with reducing mortality rates in males. The largest increases in mortality rates were observed in the United Kingdom (males +140.4%, females +158.0%) and the United States (males +125.7%, females +131.2%). We observed an overall upward trend for mortality-to-incidence indices between 1990-2017 in all EU15+ countries for females, and in 18 of 19 EU15+ countries for males. The mortality-to-incidence trend was reducing only for males in Italy. Conclusion: We identify shifting burden of PAD in EU15+ countries, with increasing mortality rates despite reducing incidence over the past 27-years. Strong evidence supports goal-directed medical therapy in reducing PAD mortality, however inadequate compliance with medical therapy has been reported: population-wide strategies to improve compliance are called for. [Trends in PAD incidence. Squares indicate males; and circles, females] [Trends in PAD mortality. Squares indicate males; and circles, females] Disclosure: Nothing to disclose

A Pilot Study: Decreased Hospitalization in Elderly Heart Failure Patients While on Sacubitril-Valsartan Combination

Introduction Sacubitril-Valsartan combination (SVC) is new to the heart failure (HF) armamentarium. SVC, in addition to HF goal directed medical therapy (GDMT), is indicated to reduce the risk of cardiovascular (CV) death and HF hospitalizations in patients with reduced ejection fraction (HFrEF). PARADIGM-HF was stopped early due to overwhelming efficacy when compared to Enalapril. SVC dosed to the target 97/103 mg twice daily, reduced the primary composite outcomes of CV death or first HF hospitalization by 20%. HF guidelines recommend SVC as an option in patients with HFrEF. In PIONEER-HF, compared to Enalapril, SVC had a greater time-averaged reduction in NT-proBNP levels (25% vs. 47%, respectively) from baseline through weeks 4 and 8 after HF hospitalization. This combination was safe and well-tolerated in both studies. Hypothesis In PARADIGM-HF and PIONEER-HF the mean age was 62 years and the majority NYHA FC II to III. Results were difficult to extrapolate in patients &gt75 years with HFrEF. This group would be excluded from advanced therapies, i.e. cardiac transplant or durable mechanical circulatory support. HF GDMT optimization is the goal for this population. In clinical trials, SVC shows significant reduction in CV death and/or HF hospitalizations compared to Enalapril. We hypothesize that the clinical outcomes of patients &gt75 years with HFrEF receiving SVC would be favorable. Methods A retrospective chart review was conducted in a community hospital between January 2016 and December 2017. Subjects were identified via electronic health record. Inclusion criteria included age &gt 75 years, left ventricular ejection fraction &lt 40%, on maximally tolerated GDMT and SVC initiated during hospitalization. Subjects were excluded if SVC was not continued at discharge or lost to follow up. The clinical outcomes were CV death or first 30-day HF readmission, change in renal function or blood pressure. Descriptive statistics were used for data analysis. Results Inclusion criteria was met in 34 patients. Baseline characteristics: mean age 81 years, female 50%, mean weight 75 kg, BMI of 25, Caucasians 79% and mean ejection fraction 26%. Mean NT-ProBNP change from baseline was -68%. The first 30-day HF readmission was 14.7%. No patients were discharged on intravenous inotropes and no mortality reported. Conclusions SVC appears to lower first 30-day HF hospital readmissions in patients &gt 75 years old. It is well-tolerated among this population. Further, well-designed study was warranted.

Implantable Cardioverter Defibrillator Use in Males with Duchenne Muscular Dystrophy and Severe Left Ventricular Dysfunction

Purpose Duchenne muscular dystrophy (DMD) is characterized by myocardial fibrosis and left ventricular (LV) dysfunction. Implantable cardioverter defibrillator (ICD) use has not been characterized in this population but is generally considered for patients with severe LV dysfunction receiving goal directed medical therapy (GDMT), including a beta blocker plus an angiotensin converting enzyme inhibitor. We evaluated utilization and efficacy of ICD use in patients with DMD. Methods Retrospective cohort study of DMD patients followed at 17 centers across the US and Canada from January 2, 2005-January 1, 2018. ICD use and its effect on survival was evaluated in those patients with severe LV dysfunction (shortening fraction (SF) Results Severe LV dysfunction was present in 57/436 (13.1%) patients, of which 11 (19.3%) died during the study period, as compared to 17/379 (4.5%) who died without severe LV dysfunction (p Conclusion ICD use may be associated with improved survival and minimal complications in DMD cardiomyopathy with severe LV dysfunction. However, inconsistent utilization of GDMT may be a significant confounder.Future studies are needed to define optimal ICD use in patients with DMD related cardiomyopathy.

Pontine Infarct Camouflaged as Bell’s Palsy

Facial palsy is a neurological disorder triggered by dysfunction of the seventh cranial nerve, categorized as either central, between the cerebral cortex and brainstem nuclei, or peripheral, between the brainstem nuclei and peripheral organs. Central lesions cause impairment of the contralateral lower facial musculature with associated sparing of the forehead and ocular muscles. Conversely, peripheral lesions produce ipsilateral whole-sided facial hemiplegia including both forehead and ocular muscles. Facial palsy is diagnosed clinically, while imaging studies and additional subsidiary testing (e.g. electromyography, nerve conduction studies), serologies, and rarely biopsy can assist in confirming or refuting the working diagnosis. The differential diagnosis comprises Bell’s palsy (idiopathic), HIV infection, Ramsey Hunt syndrome, Lyme, sarcoidosis, amyloidosis, acoustic neuroma, parotid gland tumor, temporal bone biopsy, otitis media, Guillain-Barre syndrome, and brainstem infarct. Facial palsy is branded as Bell’s palsy if one of the aforementioned etiologies is not identified as the root cause. Herein, we report the case of a 58-year-old male, who presented with left facial weakness involving both the upper and lower face, posterior circulation symptoms in the setting of hypertensive emergency. Initial magnetic resonance imaging (MRI) was unrevealing for any acute process, however given lack of improvement repeat imaging was ordered. The patient was ultimately confirmed to have an acute versus subacute pontine infarct where the seventh and eighth cranial nerve exits at the cerebellopontine angle. Ancillary laboratory studies were non-contributory. Subsequently, the patient’s symptoms continued to improve, blood pressure control was achieved, and was consequently discharged on goal-directed medical therapy. J Neurol Res. 2019;9(1-2):14-17 doi: https://doi.org/10.14740/jnr524

Pontine Infarct Camouflaged as Bell’s Palsy

Facial palsy is a neurological disorder triggered by dysfunction of the seventh cranial nerve, categorized as either central, between the cerebral cortex and brainstem nuclei, or peripheral, between the brainstem nuclei and peripheral organs. Central lesions cause impairment of the contralateral lower facial musculature with associated sparing of the forehead and ocular muscles. Conversely, peripheral lesions produce ipsilateral whole-sided facial hemiplegia including both forehead and ocular muscles. Facial palsy is diagnosed clinically, while imaging studies and additional subsidiary testing (e.g. electromyography, nerve conduction studies), serologies, and rarely biopsy can assist in confirming or refuting the working diagnosis. The differential diagnosis comprises Bell’s palsy (idiopathic), HIV infection, Ramsey Hunt syndrome, Lyme, sarcoidosis, amyloidosis, acoustic neuroma, parotid gland tumor, temporal bone biopsy, otitis media, Guillain-Barre syndrome, and brainstem infarct. Facial palsy is branded as Bell’s palsy if one of the aforementioned etiologies is not identified as the root cause. Herein, we report the case of a 58-year-old male, who presented with left facial weakness involving both the upper and lower face, posterior circulation symptoms in the setting of hypertensive emergency. Initial magnetic resonance imaging (MRI) was unrevealing for any acute process, however given lack of improvement repeat imaging was ordered. The patient was ultimately confirmed to have an acute versus subacute pontine infarct where the seventh and eighth cranial nerve exits at the cerebellopontine angle. Ancillary laboratory studies were non-contributory. Subsequently, the patient’s symptoms continued to improve, blood pressure control was achieved, and was consequently discharged on goal-directed medical therapy. J Neurol Res. 2019;9(1-2):14-17 doi: https://doi.org/10.14740/jnr524

Cardiac Resynchronization Therapy-Emerging Therapeutic Approaches.

Cardiac resynchronization therapy (CRT) is an important therapeutic tool in the management of patients with heart failure and electrical dyssynchrony. In appropriately selected patients, landmark randomized controlled trials have demonstrated morbidity and mortality benefit beyond standard goal-directed medical therapy. Current guidelines emphasize the greatest clinical efficacy of CRT in patients with symptomatic heart failure, left bundle branch block, and wide QRS duration (> 150ms). Other relevant considerations include the presence of atrial fibrillation, the presence of AV block, the etiology of cardiomyopathy, the presence of masked left-sided conduction delay, and the impact of comorbidities that might predict poor clinical response. At the time of CRT implantation, key considerations include targeting of the left ventricular (LV) lead to sites of greatest electrical and/or mechanical delay, the use of quadripolar versus bipolar LV pacing leads, evaluation of multiple pacing vectors to maximize electrical resynchronization, and in select instances pre-procedure imaging of the coronary venous anatomy to help guide decision-making at the time implant. Post-implant care includes the selective use of atrio-ventricular and inter-ventricular optimization algorithms, mitigation of right ventricular pacing, recognition, and treatment of suboptimal biventricular pacing, as well as management by a multi-disciplinary team of cardiovascular specialists. Emerging therapeutic strategies for patients eligible for CRT include the use of endocardial LV pacing, novel LV pacing options including multi-point pacing, His bundle pacing, and the integration of remote monitoring platforms that may identify patients at risk for clinical worsening.

Device Management in Heart Failure.

Medical devices have become an integral part of comprehensive heart failure management. Not all heart failure patients, however, accrue benefit from every new device, and even with extensive practice guidelines, this remains an evolving field. The addition of implantable devices, like internal cardioverter defibrillators (ICDs), and novel pacing technologies, including cardiac resynchronization therapy (CRT), have helped to compliment goal-directed medical therapy and positively impact prognosis in multiple high-quality clinical trials. This review attempts to summarize the rapidly evolving literature with respect to existing device guidelines for routine implantable devices as well as some available and future technologies that are not yet a part of routine guidelines. ICD, CRT, and other implantable devices continue to save lives, decrease hospitalizations, and evolve the management of patients with heart failure beyond the capabilities of optimal guideline-directed medical therapy alone.

Abstract 076: Modeling Heterogeneity of Benefit in Patients Eligible for Implantable Cardiac Defibrillators: Insights From the SCD-HeFT Registry

Background: Guidelines recommend that patients with heart failure and reduced ejection fraction (&lt;35%; HFrEF), on goal-directed medical therapy be considered for placement of an implantable cardiac defibrillator (ICD) for primary prevention of sudden cardiac death. This recommendation arose from the results of the SCD-HeFT trial, where there was a 7% absolute mortality reduction at 5 years in those who got an ICD. However, the application of these guidelines has been suboptimal and it is unknown if particular patient characteristics drive this benefit. Methods: We used patient-level data from the multi-center SCD-HeFT trial to examine the heterogeneity of the primary outcome (5-year all-cause mortality) in 1676 patients randomized to placebo or ICD (excluding those randomized to amiodarone). We used step-wise variable selection to select the variables for the final model. A cox proportional hazards model was then applied to develop a prediction tool to estimate patient benefit with ICD. Results: After variable selection, the following variables were found to be significantly associated with an increased risk of mortality over 5 years: older age, male sex, ischemic heart disease, diabetes, higher NYHA class, lower LVEF, diuretic use, lower mean blood pressure, higher blood urea nitrogen, and randomization to placebo (see Figure 1). There was a significant interaction of treatment allocation with diabetes, where the benefit of ICDs was greatest amongst those without diabetes (HR placebo vs. ICD amongst diabetics, 6.33, 95% CI 2.40-20.91; p &lt; 0.001). Conversely, among diabetics ICD therapy was associated with an increased risk of mortality when compared to medical therapy (HR 6.39, 95% CI 2.51-15.95; p &lt; 0.001). The c-statistic for the model was 0.73. Conclusion: There is substantial heterogeneity of treatment benefit from an ICD for primary prevention of 5-year all-cause mortality. If validated in a distinct and more contemporary dataset, this model may have an important role in patient selection and shared decision-making.

Health Care Goals, Communication, and Knowledge Among Older ICD Recipients

Introduction: It is well established that among patients with heart failure (HF), half have heart failure with preserved ejection fraction (HFpEF). Heart failure, regardless of etiology, remains the leading cause of hospitalization among adultsO65 years of age, accounting for a total Medicare expenditure exceeding $17 billion. While certain interventions help reduce heart failure readmissions, it is ambiguous whether those interventions can be beneficial in patients with HFpEF. Hypothesis: Implementing strategies to improve admission and discharge follow up will reduce heart failure readmissions in patients with HFrEF and HFpEF. Methods: Retrospective analysis of admissions in our hospital in year 2014 revealed that 897 admissions carried the primary diagnosis of heart failure. The interventions implemented included, palliative care consult, goal-directed medical therapy (GDMT), and initiation of 7 day follow up visits. Readmissions rate were grouped based on the nature of heart failure, HFrEF !40% and HFpEF O40%. Results: Of the 897 readmissions in our hospital in 2014, 66 were due to HF exacerbations, and 165 readmissions had other primary diagnoses but with underlying HF pathology. The majority of readmissions were patients with underlying HFpEF rather than HFrEF. Sixty-one percent (40/66) of the heart failure readmissions were attributed to HFpEF alone, and 71% (117/165) of all-cause readmissions were patients with underlying HFpEF. Regardless of the nature of the heart failure, patients did not differ significantly background interventions; including follow-up appointments post discharge, GDMT, and palliative care consultation. Conclusions: Although the trend was towards reduced 30-day heart failure readmissions, the measures were less effective on those who had heart failure with preserved ejection fraction

Therapeutic adjustments in stage D heart failure: challenges and strategies.

The morbidity and mortality associated with heart failure (HF) represents a significant public health challenge. Stage D HF identifies a distinct subgroup of advanced HF patients characterized by adverse clinical and hemodynamic factors which warrant evaluation for specialized advanced management strategies and/or consideration of palliative care in tandem with the same recommendations for goal-directed optimal medical therapy as earlier stages of HF. In fact, one of the inherent markers of progression to stage D disease is the need to withdraw previously tolerated neurohormonal agents in the setting of systemic circulatory limitations or renal dysfunction. Furthermore, the requirement for aggressive diuresis in the setting of borderline blood pressures and renal insufficiency is often complicated by worsening renal impairment. Assessment of the appropriate need for inotropic support, given the significant complications associated with their use, is also a frequently encountered challenge complicating the medical management of Stage D HF. This review outlines some of the most relevant challenges of pharmacological therapy in stage D HF and describes current and future strategies that may be employed to overcome some of these obstacles.

Intractable epistaxis and systemic lupus: High-dose intravenous pulse steroids

ImportanceEpistaxis is most commonly an easily treated ENT entity with a relatively simple algorithm. Occasionally, however, it is encountered as a devastating disease process that can humble the otolaryngologist. In the setting of comorbidities that exacerbate bleeding, in this case vasculitis due to systemic lupus erythematosus (SLE), epistaxis can be life-threatening and refractory to conservative management. ObservationsThis case report describes the hospital course of a patient with severe SLE and intractable epistaxis. We discuss classic management options for epistaxis and offer a novel treatment option for patients with SLE-related vasculitides—goal-directed medical therapy with high-dose intravenous pulse steroid therapy. Conclusions and RelevanceTo our knowledge, this report not only is the first description of targeted treatment options for intractable epistaxis in patients with SLE, but also serves to augment the traditional algorithm with the addition of a goal-directed medical therapy—control of epistaxis through high-dose intravenous pulse steroid therapy. We demonstrated that 6mg of intravenous dexamethasone given every 6hours can be highly effective in controlling epistaxis in patients with uncontrolled SLE. The presumed mechanism is through control of associated vasculitides.

Goal-directed medical therapy and point-of-care testing improve outcomes after congenital heart surgery

A goal-directed therapy algorithm based on serial lactate values obtained from a point-of-care testing device was utilized in an attempt to reduce the mortality of patients after congenital heart surgery. Prospective study of patients undergoing surgery utilizing a goal-directed therapy algorithm in the postoperative period. The results of this group are compared with a historical cohort. Operative risk was determined using the RACHS-1 scoring system. A 12-bed cardiac intensive care unit (ICU) in a pediatric hospital. Patients undergoing surgery from July 2001 through September 2003 (group B, n=710) were compared to cohorts from June 1995 through June 2001 (group A, n=1,656). Group B patients were smaller and younger (median weight 6.2 vs 8 kg, p<0.001; median age 184 vs 327 days, p=0.004). Beginning in July 2001, blood lactate measurements were performed serially for 24 h after heart surgery. Based on lactate values and trends, therapy was amended. Mortality was lower for group B (1.8 vs 3.7%, p=0.02). A reduction in mortality between group B and group A was noted in neonates (3.4 vs 12%, p=0.02), but not in older patients. Group B patients undergoing higher risk operations (Risk Adjustment for Congenital Heart Surgery-1 [RACHS-1] categories 3-6) had a significant reduction in mortality when compared to group A (3 vs 9%, p=0.006), no difference was noted in patients undergoing lower risk operations (RACHS-1 categories 1 and 2). The combination of goal-directed therapy and point-of-care testing was associated with a marked decrease in mortality for patients undergoing congenital heart surgery. Improvement was greatest in the highest risk patients.

Psychological treatment modalities for pain in cancer patients.

Psychological therapies such as hypnosis and autogenic training may be used to treat pain in the cancer patient. Some patients may draw relatively small benefit from these methods, while others benefit more significantly. These methods may result in the diminution of anxieties, hope for mitigation of pain, lessening of feelings of isolation, the experience of goal-directed medical therapy, as well as the feeling of belonging to a group. The more general effects apart from the goals of the specific therapy relate to emotional factors essential for the experience and tolerance of pain. Therefore, a more general psychological treatment should be based on the comprehension of and should deal with the psychological and social problems that appear in the course of a neoplastic disease.