Time Of Heart Failure Research Articles

Short- and long-term mortality and hospital readmissions among patients with new hospitalization for heart failure: A population-based investigation from Italy

ObjectivePredictors of mortality and readmission among patients hospitalized for the first time for heart failure (HF) were investigated for a large, unselected population. MethodsThe cohort of 13,171 patients in the Lombardy Region (Italy), all of whom were aged 50years or older and survived their first hospitalization for HF during 2011, were followed after discharge. Mortality and readmission within 30days and one year of index discharge were investigated. Kaplan–Meier estimator and Cox model were respectively used to estimate the cumulative proportions of patients experiencing the outcomes and the hazard ratio (HR) for the association between selected covariates and time of outcome onset. ResultsWithin 30days of index discharge, 4.7% and 4.3% of the cohort members died or were readmitted for HF, respectively, while 22.6% and 57.2% of them died or were readmitted for any cause within one year of index discharge. Older age was an independent predictor of mortality at both 30days and one year. One-year mortality was affected by the use of diuretics, mineralocorticoid receptor antagonists and antigout preparations and by previous hospitalization for respiratory and cerebrovascular diseases. Younger age, use of antidiabetics, diuretics, other antihypertensives, NSAIDs and antigout preparations and previous hospitalization for renal, respiratory, coronary heart and cerebrovascular disease, were independent predictors of hospital readmission. ConclusionShort- and long-term mortality and readmissions after first hospitalization for HF are high and heterogeneous across different patient subgroups. Characterization of hospitalized HF is very important in assisting clinicians in decision-making and targeting treatment of high-risk patients.

Predictors of late-onset heart failure in breast cancer patients treated with doxorubicin.

Anthracyclines are an integral component of breast cancer chemotherapy. They exert many cardiotoxic effects, including heart failure. The onset of anthracycline-induced heart failure (AIHF) can occur years after completion of chemotherapy and incurs significant morbidity and mortality. Few studies have attempted to characterize risk factors for its development. Our purpose was to determine the incidence of early and late AIHF in breast cancer survivors and to identify factors that increase the risk for late-onset AIHF. Patients with invasive breast cancer who received doxorubicin-containing chemotherapy at University Hospitals Case Medical Center from 1998 to 2006 were included. Medical history and tumor and treatment characteristics were abstracted from medical records. Patients who developed heart failure were compared to those who did not and were also stratified based on timing of heart failure. One thousand one hundred fifty-three patients received doxorubicin-based chemotherapy for invasive breast cancer with an average follow-up of 7.6 years (standard deviation (SD) = 3.4). The overall incidence of heart failure was 10.4, with a 2.9 and 7.6 % incidence of early- and late-onset heart failure, respectively. Human epidermal growth factor receptor 2 (HER2) status, hypertension, and coronary artery disease were significant predictors for both heart failure groups (p < 0.001). Type II diabetes was a risk factor for the late-onset AIHF group (p < 0.001). HER2 status and cardiovascular risk factors increased the risk of heart failure among doxorubicin users. Patients with type II diabetes were at increased risk of late-onset AIHF. We identified at risk survivors who may benefit from prolonged monitoring and/or early intervention.

0300: Systemic delivery of AAVrh10 expressing frataxin corrects the severe mitochondrial cardiomyopathy of frataxin deficient mice

Cardiac failure is the most common cause of mortality in Friedreich ataxia (FRDA), a mitochondrial disease with neurodegeneration, hypertrophic cardiomyopathy and diabetes. FRDA is caused by reduced levels of frataxin (FXN), an essential mitochondrial protein involved in mitochondrial bioenergetics. To date, no treatment exists for FRDA cardiomyopathy. Here, we show that adenoassociated virus (AAV) rh10 vector expressing human FXN injected intravenously not only prevented the onset of the cardiac disease in a faithful FRDA cardiac mouse model, but also, when administered at the time of heart failure, reversed rapidly and completely cardiac disease at the functional, cellular and molecular level in all treated animals. Our results also demonstrate the capacity of defective cardiomyocytes with severe energy failure and ultrastructure disorganization to be rapidly corrected and remodeled by gene therapy. These results establish the primary proof-of-concept for developing gene therapy of FRDA cardiomyopathy.

Diagnosis of Cardiac Amyloidosis by Skin Lesions

In June 2011, a 74-year-old man was admitted for recurrent heart failure. He had hypertension, diabetes mellitus, renal failure due to nephrosclerosis and diabetic nephropathy, prostate cancer, tuberculosis, and gouty arthritis, and had received a parathyroidectomy. In 2009, he had received a mechanical prosthesis to treat aortic stenosis. Cardiac auscultation was rhythmic, with no murmurs, and with normal prosthetic sounds. The patient presented petechiae, purpura, papules, and spontaneous ecchymosis at the eyelids, groin, neck, and axillas (Figure 1), with onset after initiation of acenocoumarol in 2009. The electrocardiogram demonstrated sinus rhythm with a long P-R interval, right bundle branch block with left anterior hemiblock, and low voltage, consistent with infiltrative cardiomyopathy (Figure 2). The echocardiogram demonstrated left ventricular hypertrophy with increased echogenicity (Figures 3A and B), ejection fraction of 45%, and a restrictive pattern on pulsed Doppler (Figure 3C: increased E/A ratio) and tissue Doppler (Figure 3D: decreased E’ and A’ peaks). Examination of skin biopsy specimens with Congo red stain showed amyloidosis secondary to monoclonal gammopathy, with positive immunohistochemistry for lambda light chains. He was treated with melphalan and dexamethasone, which were discontinued because of a favorable hematological response, with normalization of serum free light chain concentrations. Thereafter, he was hospitalized several times for heart failure and ultimately died of this cause in 2013. The purpura, petechiae, and ecchymosis were due to intracutaneous bleeding, resulting from a fragile vascular status secondary to amyloid infiltration. This is sometimes the first and only sign of systemic amyloidosis. Although these features are not specific to this disease, they may be an aid to its diagnosis and prompt treatment in the appropriate clinical context. Figure 3. Figure 1. I

Two-year outcome of patients after a first hospitalization for heart failure: A national observational study

National population-based management and outcome data for patients of all ages hospitalized for heart failure have rarely been reported. National population-based management and outcome of patients of all ages hospitalized for heart failure have rarely been reported. The present study reports these results, based on 77% of the French population, for patients hospitalized for the first time for heart failure in 2009. The study population comprised French national health insurance general scheme beneficiaries hospitalized in 2009 with a principal diagnosis of heart failure, after exclusion of those hospitalized for heart failure between 2006 and 2008 or with a chronic disease status for heart failure. Data were collected from the national health insurance information system (SNIIRAM). A total of 69,958 patients (mean age, 78 years; 48% men) were studied. The hospital mortality rate was 6.4%, with 1-month, 1-year and 2-year survival rates of 89%, 71% and 60%, respectively. Heart failure and all-cause readmission-free rates were 55% and 43% at 1 year and 27% and 17% at 2 years, respectively. Compared with a reference sample of 600,000 subjects, the age- and sex-standardized relative risk of death was 29 (95% confidence interval [CI] 28-29) at 2 years, 82 (95% CI 72-94) in subjects aged<50 years and 3 (95% CI 3-3) in subjects aged ≥ 90 years. For subjects aged < 70 years who survived 1 month after discharge, factors associated with a reduction in the 2-year mortality rate were: female sex; age < 55 years; absence of co-morbidities; and use of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, beta-blockers, lipid-lowering agents or oral anticoagulants during the month following discharge. Poor prognostic factors were treatment with a loop diuretic before or after hospitalization and readmission for heart failure within 1 month after discharge. This large population-based study confirms the severe prognosis of heart failure and the need to promote the use of effective medications and management designed to improve survival.

Aortic Valve Stenosis and Atrial Fibrillation Influence Plasma Fibulin-1 Levels in Patients Treated with Coronary Bypass Surgery

Objectives: Aortic valve stenosis (AS) causes cardiac fibrosis and left ventricular hypertrophy, and over time heart failure can occur. To date, a reliable marker to predict progression of AS or the development of heart failure is still lacking. In this study, we addressed the hypothesis that fibulin-1 levels reflect myocardial fibrosis. Methods: Patients undergoing heart surgery at the Odense University were investigated. By 2012 data on outcome were obtained. Results: In 293 patients, plasma fibulin-1 levels were measured. Patients with AS or atrial fibrillation (AF) had significantly higher fibulin-1 levels compared to those with coronary artery disease only (p = 0.005). Patients with preoperatively diagnosed chronic AF had significantly higher levels of fibulin-1 compared to those without (p = 0.004). Plasma fibulin-1 levels showed no relationship to echocardiographic size and had no impact on outcome, death or other adverse events. Conclusion: This study shows that plasma fibulin-1 levels are increased in patients with AS and AF compared to patients with coronary disease only. Our study results suggest fibulin-1, a vascular extracellular matrix (ECM) protein, as a marker of ECM turnover perhaps due to the increased myocardial stretch that is related to pressure overload.

Heart Failure Complicating Non–ST-Segment Elevation Acute Coronary Syndrome: Timing, Predictors, and Clinical Outcomes

This study sought to describe the occurrence and timing of heart failure (HF), associated clinical factors, and 30-day outcomes in patients with non-ST-segment elevation acute coronary syndromes (NSTE-ACS). Little is known about HF-complicating NSTE-ACS. Using pooled patient-level data from 7 clinical trials from 1994 to 2008, we describe the occurrence and timing of HF, associated clinical factors, and 30-day outcomes in NSTE-ACS patients. HF at presentation was defined as Killip classes II to III; patients with Killip class IV or cardiogenic shock were excluded. New in-hospital cases of HF included new pulmonary edema. After adjusting for baseline variables, we created logistic regression models to identify clinical factors associated with HF at presentation and to determine the association between HF and 30-day mortality. Of 46,519 NSTE-ACS patients, 4,910 (10.6%) had HF at presentation. Of the 41,609 with no HF at presentation, 1,194 (2.9%) developed HF during hospitalization. A total of 40,415 (86.9%) had no HF at any time. Patients presenting with or developing HF during hospitalization were older, more often female, and had a higher risk of death at 30 days than patients without HF (adjusted odds ratio [OR]: 1.74; 95% confidence interval: 1.35 to 2.26). Older age, higher presenting heart rate, diabetes, prior myocardial infarction (MI), and enrolling MI were significantly associated with HF during hospitalization. In this large cohort of NSTE-ACS patients, presenting with or developing HF during hospitalization was associated with an increased risk of 30-day mortality. Research targeting new strategies to prevent and manage HF in this high-risk population is needed.

Abstract 157: The Relationship between Readmission Cost and Total Cost Over Time for Heart Failure

Background: The dominant healthcare payment model in the US, fee-for-service, provides incentives to deliver costlier care for heart failure and disincentives to deliver higher quality care. One proposed method to align cost and quality incentives is to impose financial penalties on providers when patients are readmitted within 30 days after a heart failure hospitalization. We hypothesized that this strategy might not lower overall costs, because lower readmission costs might be offset by higher non-readmission post-acute care costs. Methods: We studied cost to Medicare from 2008-09 for all heart failure hospitalizations (MS-DRG 291, 292, or 293) in the 15 healthcare delivery systems participating in the High Value Health Collaborative. We categorized costs for the 30, 90, and 180 days after the day of admission for first heart failure hospitalization in the study period into acute care costs (inpatient care, outpatient facility costs with 3 day look back window, part B professional fees), inpatient readmission cost, and non-readmission post-acute care costs (outpatient facility fee, sub-acute rehab, inpatient rehab, long term care, home health care, part B professional fees). Results: Using the most common MS DRG (DRG 292) as an example, across the 15 healthcare systems, we found wide variation in median total costs for the 30- ($6487-$11565), 90- ($8049-$18918), and 180- ($9844-$24752) day time frames. For the 30-day time frame, readmission costs ($700 - $2684) and non-readmission post-acute care costs ($477 - $6398) also showed wide variation. The Figure is a plot of these two costs, with bubbles sized to reflect the number of cases for the hospital system (30-day time frame); results were comparable for 90 and 180 days. Contrary to our hypothesis, we found no inverse relationship between readmission costs and non-readmission post-acute care costs. These data do not account for possible differences in case mix and in geographic differences in labor and facility costs. Conclusions: Non-readmission post-acute costs for heart failure are unrelated to readmission costs but were greater than readmission costs in a number of healthcare deliver systems, raising questions about the overall value to the healthcare systems of an exclusive focus on readmission as a strategy for reducing the costs of heart failure.

National trends in heart failure hospital stay rates, 2001 to 2009.

This study sought to analyze recent trends over time in heart failure (HF) hospital stay rates, length of stay (LOS), and in-hospital mortality by age groups with a large national dataset of U.S. hospital discharges. Heart failure hospital stay rates, LOS, and mortality have fallen over the past decade for older Medicare beneficiaries, but whether this holds true for younger adults is unknown. From the National Inpatient Sample, we calculated HF hospital stay rates, LOS, and in-hospital mortality from 2001 to 2009 with survey data analysis techniques. Hospital stays (n = 1,686,089) with a primary discharge diagnosis of HF were identified from National Inpatient Sample data between 2001 and 2009. The overall national hospital stay rate decreased from 633 to 463 hospital stays/100,000 persons, (-26.9%, p-for-trend <0.001). However, statistically significant declines (p < 0.001) were only observed for patients 55 to 64 years of age (-36.5%) 65 to 74 years (-37.4%), and ≥ 75 years (-28.3%) but not for patients 18 to 44 years of age (-12.8%, p = 0.57) or 45 to 55 years (-16.2%, p = 0.04). Statistically significant declines in LOS were only observed for patients 65 years of age and older. Overall in-hospital mortality fell from 4.5% to 3.3%, a relative decline of -27.4%, (p-for-trend <0.001), but patients 18 to 44 years of age did not exhibit a significant decline (-8.1%, p-for-trend = 0.18). In secondary analyses significant declines in HF hospital stay rate over time were observed for white men, white women, and black women but not for black men (-9.5%, p-for-trend = 0.43). Younger patients have not experienced comparable declines in HF hospital stay, LOS, and in-hospital mortality as older patients. Black men remain a vulnerable population for HF hospital stay.

Zentrale Hämodynamik bei Adipositas

Duration and severity of obesity is a risk factor for developing left ventricular dysfunction, manifest cardiac damage and heart failure. To fulfill the increased energy demand with excessive body weight, the organism responds by phyiologic adaptation mechanism such as an increased blood volume, and structural and functional cardiac adaptations. These adaptations result in an increased stroke volume and cardiac output at rest and during exercise. In early stages of obesity an increased cardiac load is resulting in ventricular remodelling and diastolic dysfunction. As obesity becomes chronic a progressive impairment of diastolic and systolic function ensues, and finally a development of left heart failure. Therefore, already in early stages of cardiac overload and left ventricular dysfunction a sufficient and sustainable weight reduction should be targeted avoiding an impairment of diastolic and systolic function and development of heart failure in time.

Divergent Trends in Survival and Readmission Following a Hospitalization for Heart Failure in the Veterans Affairs Health Care System 2002 to 2006

Abstract. Objectives. This study sought to determine recent trends over time in heart failure (HF) hospitalization, patient characteristics, treatment, rehospitalization, and mortality within the Veterans Affairs health care system. Background. Use of recommended therapies for HF has increased in the United States; however, it is unclear to what extent hospitalization rates and the associated mortality have improved. Methods. We compared rates of hospitalization for HF, 30-day rehospitalization for HF, and 30-day mortality following discharge from 2002–2006 in the Veterans Affairs health care system. Odds ratios for outcome were adjusted for patient diagnoses within the past year, laboratory data, and clustering of patients within hospitals. Results. We identified 50,125 patients with a first hospitalization for HF from 2002–2006. Mean age did not change (70 years), but increases were noted for most comorbidities (mean Charlson score increased from 1.72 to 1.89; P<.0001). HF admission rates remained constant at about 5 per 1000 veterans. Mortality at 30 days decreased (7.1%–5.0%; P<.0001), whereas rehospitalization for HF at 30 days increased (5.6%–6.1%; P=.11). After adjustment for patient characteristics, the odds ratio for rehospitalization in 2006 (vs 2002) was 0.54 (95% confidence interval [CI], 0.47–0.61) for mortality, but 1.21 (95% CI, 1.04–1.41) for HF rehospitalization at 30 days. Conclusions. Recent mortality and rehospitalization rates in the Veterans Affairs health care system have trended in opposite directions. These results have implications for using rehospitalization as a measure of quality of care.—Heidenreich PA, Sahay A, Kapoor JR, et al. Divergent trends in survival and readmission following a hospitalization for heart failure in the Veterans Affairs health care system 2002 to 2006. J Am Coll Cardiol. 2010;56:362–368.

Metformin treatment is associated with a low risk of mortality in diabetic patients with heart failure: a retrospective nationwide cohort study

The safety of metformin in heart failure has been questioned because of a perceived risk of life-threatening lactic acidosis, though recent studies have not supported this concern. We investigated the risk of all-cause mortality associated with individual glucose-lowering treatment regimens used in current clinical practice in Denmark. All patients aged ≥ 30 years hospitalised for the first time for heart failure in 1997-2006 were identified and followed until the end of 2006. Patients who received treatment with metformin, a sulfonylurea and/or insulin were included and assigned to mono-, bi- or triple therapy groups. Multivariable Cox proportional hazard regression models were used to assess the risk of all-cause mortality. A total of 10,920 patients were included. The median observational time was 844 days (interquartile range 365-1,395 days). In total, 6,187 (57%) patients died. With sulfonylurea monotherapy used as the reference, adjusted hazard ratios for all-cause mortality associated with the different treatment groups were as follows: metformin 0.85 (95% CI 0.75-0.98, p = 0.02), metformin + sulfonylurea 0.89 (95% CI 0.82-0.96, p = 0.003), metformin + insulin 0.96 (95% CI 0.82-1.13, p = 0.6), metformin + insulin + sulfonylurea 0.94 (95% CI 0.77-1.15, p = 0.5), sulfonylurea + insulin 0.97 (95% CI 0.86-1.08, p = 0.5) and insulin 1.14 (95% CI 1.06-1.20, p = 0.0001). Treatment with metformin is associated with a low risk of mortality in diabetic patients with heart failure compared with treatment with a sulfonylurea or insulin.

P04 Age- and gender-specific risk of death after first hospital admission for heart failure

ObjectiveHeart failure (HF) is an important public health problem. Detailed information on prognosis following hospital admission is crucial for cost-effectiveness analysis and determination of the burden of HF on the...

Are Multiple Biomarker Testing Strategies Ready for Prime Time in Heart Failure?

In patients with heart failure, the promise that biomarkers may provide has been extensively explored. Although brain natriuretic peptide (BNP) had been proposed as a potential tool for screening patients with left ventricular systolic dysfunction, subsequent studies suggested that the biomarker had little benefit in this context.1 Indeed, the utility of BNP is perhaps most valuable when used in the more restricted and specific diagnostic context of the dyspneic patient without a clear-cut diagnosis.2 The potential utility of biomarkers for heart failure has been explored to a greater degree in the context of prognosis.3–5 However, the utility of any biomarker should be demonstrated to be incrementally better when compared to optimal clinical prediction models and other potential candidate biomarkers.6 Prior studies evaluating the prognostic utility of biomarkers in heart failure were often limited in this context. Article see p 393 In this issue of Circulation: Heart Failure , Dunlay et al7 have published the results of a study from the Mayo Clinic examining multiple biomarkers when used for prognostication of community patients with heart failure. Three currently available biomarkers, including C-reactive protein (CRP), troponin T, and BNP were examined in comparison with a clinical model for mortality risk. The combination of biomarkers, and in particular CRP and BNP, increased significantly the discrimination of the model for prediction of 1-year mortality risk, suggesting the exciting possibility that this combination of biomarkers may be clinically …

Beta-blocker Use at Discharge in Patients Hospitalized for Heart Failure is Associated With Improved Survival: An Analysis From JCARE-CARD

Background: Previous registry data demonstrated that beta-blocker use at the time of heart failure (HF) hospital discharge significantly associated with an early survival benefit in HF patients. However, it is unknown whether this therapeutic approach can also improve the long-term survival. We thus examined the long-term effects of beta-blocker use at discharge on outcomes in patients hospitalized for HF and left ventricular systolic dysfunction (LVSD). Methods and Results: The JCARE-CARD is designed to study prospectively the characteristics, treatment, and outcomes in patients hospitalized with HF throughout Japan between January 2004 to June 2005 and the outcomes including death and hospital readmission were followed through 2007.

Management of acute decompensated heart failure in an evidence-based era: What is the evidence behind the current standard of care?

Despite the increased mortality and morbidity in patients with acute decompensated heart failure (ADHF), its management has been based primarily on anecdotal experiences and physiologic assumptions rather than on prospective randomized controlled trials. The data on diuretics have been conflicting. Routine use of inotropes in ADHF has been clearly associated with increased mortality and morbidity, although inotropes seem to cause short-term clinical improvement. The safety of the different vasoactive medications has never been adequately confirmed in prospective trials despite their use for a long time in heart failure. Good evidence that supports the safety and efficacy of the different medications that are routinely used in ADHF is lacking. Unless properly designed prospective clinical trials are done to evaluate the safety of the various ADHF regimens, clinicians might continue to be misguided by the beneficial short-term effects at the expense of long-term mortality and morbidity.

Modelling the flow of congestive heart failure patients through a hospital system

The number of hospital admissions in England due to heart failure is projected to increase by over 50% during the next 25 years. This will incur greater pressures on hospital managers to allocate resources in an effective manner. A reliable indicator for measuring the quantity of resources consumed by hospital patients is their length of stay (LOS) in care. This paper proposes modelling the length of time heart failure patients spend in hospital using a special type of Markov model, where the flow of patients through hospital can be thought of as consisting of three stages of care—short-, medium- and longer-term care. If it is assumed that new admissions into the ward are replacements for discharges, such a model may be used to investigate the case-mix of patients in hospital and the expected patient turnover during some specified period of time. An example is illustrated by considering hospital admissions to a Belfast hospital in Northern Ireland, between 2000 and 2004.

Carvedilol use at discharge in patients hospitalized for heart failure is associated with improved survival: An analysis from Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure (OPTIMIZE-HF)

The IMPACT-HF trial demonstrated that carvedilol use at the time of heart failure (HF) hospital discharge significantly increased 90-day postdischarge treatment rates. Whether there is an early survival benefit associated with this therapeutic approach in patients hospitalized for HF is unknown. We examined the early effects on mortality and rehospitalization of carvedilol use at discharge in patients hospitalized for HF and left ventricular systolic dysfunction (LVSD) compared with outcomes in patients who are eligible for, but do not receive, beta blockers before discharge. The OPTIMIZE-HF program enrolled 5791 patients admitted with HF in a web-based registry at 91 hospitals participating with prespecified 60- to 90-day follow-up from March 2003 to December 2004. Outcomes data were prospectively collected on patients eligible for beta-blocker therapy and analyzed according to predischarge beta-blocker use. The mean age was 69.7 years; 63% were male, etiology was ischemic in 52%, and mean left ventricular ejection fraction was 24.3%. A total of 2720 patients had LVSD, among whom 2373 (87.2%) were eligible to receive a beta blocker at discharge and carvedilol was prescribed in 1162 (49.0%). Discharge use of carvedilol was associated with a significant reduction in mortality risk at 60 to 90 days (hazard ratio 0.46, P = .0006) and mortality or rehospitalization (odds ratio 0.71, P = .0175) compared to no predischarge beta blocker. Predischarge use of carvedilol was well tolerated with high rates of continued therapy at 60 to 90 days follow-up. Similar findings were observed for other evidence-based beta blockers. Carvedilol use at the time of HF hospital discharge is well tolerated, improves treatment rates, and is associated with an early survival benefit. These findings provide further support for guideline recommendations that carvedilol or other evidence-based beta blocker should be initiated before hospital discharge in stable patients with HF and LVSD.

Changes in Depression, Anxiety, and Social Support in Heart Failure Outpatients with Implantable Cardioverter Defibrillators

Objectives: This study examined changes in depression, anxiety, and social support over time in heart failure (HF) outpatients with implantable cardioverter defibrillators (ICDs) and compared them with similar patients without ICDs. Background: The Sudden Cardiac Death in Heart Failure Trial (SCD-HeFT) international clinical trial indicated that ICDs are effective for primary prevention of mortality in HF outpatients. Patients given ICDs after arrhythmic events or sudden cardiac arrest experience psychological distress. The psychosocial impact of ICDs in patients who receive them for primary prevention is unknown. Methods: SCD-HeFT patients randomly assigned to ICDs (n 5 57) or medication (n 5 96) completed depression, anxiety, and social support scales at entry and every 6 months. Results: At entry, 36% of patients with ICDs reported depression; 45% reported anxiety. In linear mixed models, depression decreased over time for patients with ICDs but did not change for those without ICDs. In HF outpatients with ICDs, anxiety was highest at entry and decreased over 2 years. Shocks did not predict depression, anxiety or social support or changes in them. Overall, social support did not change. Among patients with ICDs, changes in social support depended on the patients’ age; the younger the patient, the more social support decreased over time. Shocks did not predict psychosocial status or changes. Conclusion: Depression and anxiety are common in HF outpatients. Anxiety and depression decreased over time in patients with but not without ICDs. ICDs may provide reassurance once patients are accustomed to them.

Pathology of End-stage Remodeling in a Family of Cats with Hypertrophic Cardiomyopathy

End-stage hypertrophic cardiomyopathy (ES-HCM), affecting 5-10% of human hypertrophic cardiomyopathy (HCM) patients, is characterized by relative thinning of the ventricular walls and septum with dilation of the ventricular lumen, decreased fractional shortening, and progression to heart failure. C. J. Baty and others recently documented similar progressive changes to ES-HCM in a family of four cats through serial echocardiograms. At the time of heart failure, these cats exhibited changes similar to those exhibited by human ES-HCM patients. Our objectives were to describe the pathologic alterations associated with ES-HCM and investigate the pathogenesis in three of the four cats. Grossly, there was left atrial dilation with relative thinning of the interventricular septum (IVS) and left ventricular free wall (LVFW). The left atrium contained large thrombi in two of the three cats, and all three cats died following thromboembolization of the aortic bifurcation. Histologically, all three cats had subendocardial and myocardial fibrosis, predominantly of the IVS and LVFW, and one cat had acute, multifocal, myocardial infarcts with mononuclear inflammatory cell infiltrates. The pathogenesis of ES-HCM is uncertain, but theories implicate occlusion of the coronary blood flow by thickening of the coronary vessels, coronary vascular thromboembolism or coronary vessel spasm, apoptosis of myocytes, and myocardial hypertrophy beyond the ability of the vasculature to supply blood. Apoptosis assays did not reveal any apoptotic myocytes. Considering the hypercoagulative state of these cats, coronary vascular thromboembolism could be a major contributing factor. We cannot exclude apoptosis or coronary vessel spasm on the basis of the data presented.