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Anticoagulant Use in Heart Failure Patients with Atrial Fibrillation: Insights From the NCDR PINNACLE-AF Registry
S58 Journal of Cardiac Failure Vol. 23 No. 8S August 2017 their average CHADSVASC score is higher. These findings suggest that greater awareness of the stroke risk that HFpEF confers in AF is needed.
Figure 1. Percentage of patients with midrange left ventricle ejection fraction reporting limitations to perform daily life activities accordingly to previous ejection fraction.
152 Memory Loss and Decreased Executive Function are Associated with Functional Limitation in Patients with Heart Failure Mi-Seung Shin1, JinShil Kim2, Sun Young Hwang3, Eunok Park4, Young-Hyo Lim5, Jae Lan Shim3, Sunhwa Kim3, Minjeong An6; 1Gachon University Gil Medical Center, Incheon, Republic of Korea; 2Gachon University, College of Nursing, Incheon, Republic of Korea; 3College of Nursing, Hanyang University, Seoul, Republic of Korea; 4Jeju National University College of Nursing, Jeju, Republic of Korea; 5College of Medicine, Hanyang University Medical Center, Seoul, Republic of Korea; 6Chonnam National University, College of Nursing, Gwangju, Republic of Korea Background: This study examined cognitive domains of memory, attention, and executive function in Korean patients with heart failure (HF) and community-dwelling participants with other non-HF medical conditions (medical participants) and their effects on functional capacity. Method: Using a comparative descriptive design, 118 HF patients and 83 medical participants underwent face-to-face interviews for neuropsychological testing of cognitive status and functional capacity. Results: More HF patients had cognitive impairment in memory and executive function using the 7th percentile Z-scores of medical participants as cutoff scores: immediate (35.0% vs. 6.0%) and delayed recall memory (34.5% vs. 8.4%), and executive function (28.6% vs. 6.0%). Independent of age, education, and the presence of HF, delayed recall memory was a significant predictor (b = 1.35, p = .037), accounting for 1.4% of additional variance in functional capacity. Conclusion: Memory and executive function were worse in HF patients than medical participants, with functional limitation increasing with memory loss. Cognitive screening is recommended in routine clinical practice in patients with HF.
153 Anticoagulant Use in Heart Failure Patients with Atrial Fibrillation: Insights From the NCDR PINNACLE-AF Registry Johanna Paola Contreras1, Kimberly N. Hong1, Lucas N. Marzec2, Jonathan C. Hsu3, Christopher P. Cannon4, Song Yang4, Thomas M. Maddox2; 1Mount Sinai School of Medicine, New York, New York; 2University of Colorado School of Medicine, Denver, Colorado; 3University of California, San Diego, San Diego, California; 4Harvard Medical School, Boston, Massachusetts Background: A history of congestive heart failure symptoms, irrespective of left ventricular ejection fraction, confers an increased risk of stroke or systemic thromboembolic event and is included in the CHA2DS2-VASc risk score. However, clinicians may fail to appreciate that heart failure with preserved ejection fraction (HFPEF) is a risk factor for stroke. The practice patterns regarding the prescription of anticoagulation for patients with coincident atrial fibrillation and HFpEF, compared to those with heart failure with reduced ejection fraction (HFrEF) have not been well described. The purpose of this study was to characterize outpatient anticoagulation practice patterns in heart failure patients. Methods: The NCDR PINNACLE-AF Registry provided de-identified patient encounter data from 2008 to 2016. Patients with a history of atrial fibrillation and heart failure were included in the study (N = 305,223). The study population was then divided by ejection fraction into the following groups: HFpEF defined as an EF &ge 40% (HFpEF, n = 210,917), and HFrEF defined as an EF < 40% (HFrEF, n = 94,306). The primary outcome measure was rates of anticoagulation identified at the most recent encounter. Results: HFpEF patients, compared to HFrEF patients, had higher mean CHADSVASC 5.2 vs 4.7 (P < .001), and were more likely to be hypertensive (89% vs 81%,P < .001) and have a history of TIA (8.5% vs 6.6%, P < .001), but less likely to have diabetes (31.8% vs 32.5%, P < .001) or a history of systemic embolism (1.4% vs 1.6%, P < .001) or MI (22.9% vs 30.5%, P < .001). Rates of anticoagulation were lower in HFpEF compared to HFrEF (65.4% compared to 63.8%, RR 0.95, P < .001), even after controlling for other CHADSVASC2 components, as well as other clinical characteristics including BMI and prior revascularization. Analysis stratified by CHADS-VASC score showed that lower rates of anticoagulation persisted in the HFpEF group until CHADSVASC&ge4. (Table 1) Conclusions: HFpEF patients with atrial fibrillation have lower overall rates of anticoagulation compared to their HFrEF counterparts, even though
154 Hemodynamics Predictors of INTERMACS Defined Early Right Ventricular Failure after Left Ventricular Assist Devices William Stendardi; UCSD, San Diego, California Introduction: Right heart failure (RHF) is a frequent complication following left ventricular assist device (LVAD) implantation and is a major factor of postoperative morbidity and mortality. However, identifying LVAD patients at risk for RHF postoperatively still remains an unsolved problem. The objective of our study is to identify preoperative hemodynamics predictors of RVF during LVAD support. Methods: Patients who underwent implantation of Heartmate II or Heartware LVADs at our center between December 2011 and December 2016 were identified. Early RVF was defined according to the latest INTERMACS definition based upon both documentation of elevated central venous pressure (CVP) and manifestations of elevated CVP before discharge. Severity was further stratified according to duration of inotrope/IV vasodilator/iNO therapy as mild (≤7 days), moderate (8–14 days), and severe (>14 days or need from mechanical RV support). Results: Among 111 patients (98 male, median 64.6 years old) who underwent LVAD implantation with 88 HeartMate II (74.6%) and 28 Heartware (23%), 75 (66.4%) experienced early RV failure. Of the 75 patients who met the INTERMACS RHF definition, 32 had mild RHF (42.7%), 27 had moderate RHF (36%), and 16 had severe RHF (21.3%). Population was stratified according to moderate-severe RVF vs mild RVF. Pre-LVAD hemodynamics demonstrated significant differences in patients who experienced moderate-severe acute RHF: right atrial pressure (RAP) (14.5 Vs. 9.00 P < .002), mean pulmonary pressure (MPAP) (40.5 Vs. 35.0 P < .025) and central venous pressure (CVP)/pulmonary capillary wedge pressure (PCWP) (0.55 Vs. 0.41 P < .034). By univariate analysis RAP, MPAP and RAP/PCWP were significantly associated with risk of moderate/severe RHF. In a multivariable model only MPAP and CVP/PCWP were significantly predictive of RHF. Area under the curve analysis demonstrated MPAP (0.684) and CVP/PCWP (0.724). Conclusions: Pre-LVAD hemodynamic data can be used to stratify patients post-LVAD implantation at risk for moderatesevere RHF. This is first study to investigate the importance of pre-LVAD hemodynamics predicting early moderate or severe RHF defined using the new INTERMACS definition.
155 Survival in Cardiogenic Shock May Require Stratifying MCS Use by Hemodynamic Profiles Michael Cook1, Mike Tzeng1, Lynn R. Punnoose2; 1Temple University School of Medicine, Philadelphia, Pennsylvania; 2Temple Heart and Vascular Institute, Philadelphia, Pennsylvania Background: Increasingly, patients with cardiogenic shock (CGS) are treated with temporary mechanical circulatory support (MCS), including percutaneous devices (Tandem, Protek Duo, Impella) and venoarterial extracorporeal membrane oxygenation (VAECMO). We hypothesized that survival outcomes using different support configurations would vary based on hemodynamic profiles: biventricular (biV) failure, isolated left ventricular (LV) and right ventricular (RV) failure. Methods: From January 2013 to December 2015, we identified 14 VA-ECMO and 14 percutaneous MCS patients with invasive hemodynamics obtained prior to device implantation and with cardiac index <2.0 L/min per m2 without support or <2.2 L/min per m2 despite pharmacologic support or MCS. BiV failure defined as right atrial pressure (RA) ≥ 10 mmHg and pulmonary capillary wedge pressure (PCWP) ≥ 15 mmHg, LV failure as (PCWP) ≥ 15 mmHg, RV failure as RA ≥ 10 mmHg. Patient demographics, medical comorbidities, hemodynamics and survival were recorded. Results: Twenty five patients (89%) had biV failure, two had isolated LV and one RV failure. Causes of biV failure included acute MI (11), chronic cardiomyopathy (11), VT after revascularized MI (1), acute PE (1) and newly diagnosed ischemic cardiomyopathy (1). Of biV failure patients undergoing percutaneous MCS, only one received biventricular support (simultaneous Tandem, Protek Duo)
Figure 1. Percentage of patients with midrange left ventricle ejection fraction reporting limitations to perform daily life activities accordingly to previous ejection fraction.
152 Memory Loss and Decreased Executive Function are Associated with Functional Limitation in Patients with Heart Failure Mi-Seung Shin1, JinShil Kim2, Sun Young Hwang3, Eunok Park4, Young-Hyo Lim5, Jae Lan Shim3, Sunhwa Kim3, Minjeong An6; 1Gachon University Gil Medical Center, Incheon, Republic of Korea; 2Gachon University, College of Nursing, Incheon, Republic of Korea; 3College of Nursing, Hanyang University, Seoul, Republic of Korea; 4Jeju National University College of Nursing, Jeju, Republic of Korea; 5College of Medicine, Hanyang University Medical Center, Seoul, Republic of Korea; 6Chonnam National University, College of Nursing, Gwangju, Republic of Korea Background: This study examined cognitive domains of memory, attention, and executive function in Korean patients with heart failure (HF) and community-dwelling participants with other non-HF medical conditions (medical participants) and their effects on functional capacity. Method: Using a comparative descriptive design, 118 HF patients and 83 medical participants underwent face-to-face interviews for neuropsychological testing of cognitive status and functional capacity. Results: More HF patients had cognitive impairment in memory and executive function using the 7th percentile Z-scores of medical participants as cutoff scores: immediate (35.0% vs. 6.0%) and delayed recall memory (34.5% vs. 8.4%), and executive function (28.6% vs. 6.0%). Independent of age, education, and the presence of HF, delayed recall memory was a significant predictor (b = 1.35, p = .037), accounting for 1.4% of additional variance in functional capacity. Conclusion: Memory and executive function were worse in HF patients than medical participants, with functional limitation increasing with memory loss. Cognitive screening is recommended in routine clinical practice in patients with HF.
153 Anticoagulant Use in Heart Failure Patients with Atrial Fibrillation: Insights From the NCDR PINNACLE-AF Registry Johanna Paola Contreras1, Kimberly N. Hong1, Lucas N. Marzec2, Jonathan C. Hsu3, Christopher P. Cannon4, Song Yang4, Thomas M. Maddox2; 1Mount Sinai School of Medicine, New York, New York; 2University of Colorado School of Medicine, Denver, Colorado; 3University of California, San Diego, San Diego, California; 4Harvard Medical School, Boston, Massachusetts Background: A history of congestive heart failure symptoms, irrespective of left ventricular ejection fraction, confers an increased risk of stroke or systemic thromboembolic event and is included in the CHA2DS2-VASc risk score. However, clinicians may fail to appreciate that heart failure with preserved ejection fraction (HFPEF) is a risk factor for stroke. The practice patterns regarding the prescription of anticoagulation for patients with coincident atrial fibrillation and HFpEF, compared to those with heart failure with reduced ejection fraction (HFrEF) have not been well described. The purpose of this study was to characterize outpatient anticoagulation practice patterns in heart failure patients. Methods: The NCDR PINNACLE-AF Registry provided de-identified patient encounter data from 2008 to 2016. Patients with a history of atrial fibrillation and heart failure were included in the study (N = 305,223). The study population was then divided by ejection fraction into the following groups: HFpEF defined as an EF &ge 40% (HFpEF, n = 210,917), and HFrEF defined as an EF < 40% (HFrEF, n = 94,306). The primary outcome measure was rates of anticoagulation identified at the most recent encounter. Results: HFpEF patients, compared to HFrEF patients, had higher mean CHADSVASC 5.2 vs 4.7 (P < .001), and were more likely to be hypertensive (89% vs 81%,P < .001) and have a history of TIA (8.5% vs 6.6%, P < .001), but less likely to have diabetes (31.8% vs 32.5%, P < .001) or a history of systemic embolism (1.4% vs 1.6%, P < .001) or MI (22.9% vs 30.5%, P < .001). Rates of anticoagulation were lower in HFpEF compared to HFrEF (65.4% compared to 63.8%, RR 0.95, P < .001), even after controlling for other CHADSVASC2 components, as well as other clinical characteristics including BMI and prior revascularization. Analysis stratified by CHADS-VASC score showed that lower rates of anticoagulation persisted in the HFpEF group until CHADSVASC&ge4. (Table 1) Conclusions: HFpEF patients with atrial fibrillation have lower overall rates of anticoagulation compared to their HFrEF counterparts, even though
154 Hemodynamics Predictors of INTERMACS Defined Early Right Ventricular Failure after Left Ventricular Assist Devices William Stendardi; UCSD, San Diego, California Introduction: Right heart failure (RHF) is a frequent complication following left ventricular assist device (LVAD) implantation and is a major factor of postoperative morbidity and mortality. However, identifying LVAD patients at risk for RHF postoperatively still remains an unsolved problem. The objective of our study is to identify preoperative hemodynamics predictors of RVF during LVAD support. Methods: Patients who underwent implantation of Heartmate II or Heartware LVADs at our center between December 2011 and December 2016 were identified. Early RVF was defined according to the latest INTERMACS definition based upon both documentation of elevated central venous pressure (CVP) and manifestations of elevated CVP before discharge. Severity was further stratified according to duration of inotrope/IV vasodilator/iNO therapy as mild (≤7 days), moderate (8–14 days), and severe (>14 days or need from mechanical RV support). Results: Among 111 patients (98 male, median 64.6 years old) who underwent LVAD implantation with 88 HeartMate II (74.6%) and 28 Heartware (23%), 75 (66.4%) experienced early RV failure. Of the 75 patients who met the INTERMACS RHF definition, 32 had mild RHF (42.7%), 27 had moderate RHF (36%), and 16 had severe RHF (21.3%). Population was stratified according to moderate-severe RVF vs mild RVF. Pre-LVAD hemodynamics demonstrated significant differences in patients who experienced moderate-severe acute RHF: right atrial pressure (RAP) (14.5 Vs. 9.00 P < .002), mean pulmonary pressure (MPAP) (40.5 Vs. 35.0 P < .025) and central venous pressure (CVP)/pulmonary capillary wedge pressure (PCWP) (0.55 Vs. 0.41 P < .034). By univariate analysis RAP, MPAP and RAP/PCWP were significantly associated with risk of moderate/severe RHF. In a multivariable model only MPAP and CVP/PCWP were significantly predictive of RHF. Area under the curve analysis demonstrated MPAP (0.684) and CVP/PCWP (0.724). Conclusions: Pre-LVAD hemodynamic data can be used to stratify patients post-LVAD implantation at risk for moderatesevere RHF. This is first study to investigate the importance of pre-LVAD hemodynamics predicting early moderate or severe RHF defined using the new INTERMACS definition.
155 Survival in Cardiogenic Shock May Require Stratifying MCS Use by Hemodynamic Profiles Michael Cook1, Mike Tzeng1, Lynn R. Punnoose2; 1Temple University School of Medicine, Philadelphia, Pennsylvania; 2Temple Heart and Vascular Institute, Philadelphia, Pennsylvania Background: Increasingly, patients with cardiogenic shock (CGS) are treated with temporary mechanical circulatory support (MCS), including percutaneous devices (Tandem, Protek Duo, Impella) and venoarterial extracorporeal membrane oxygenation (VAECMO). We hypothesized that survival outcomes using different support configurations would vary based on hemodynamic profiles: biventricular (biV) failure, isolated left ventricular (LV) and right ventricular (RV) failure. Methods: From January 2013 to December 2015, we identified 14 VA-ECMO and 14 percutaneous MCS patients with invasive hemodynamics obtained prior to device implantation and with cardiac index <2.0 L/min per m2 without support or <2.2 L/min per m2 despite pharmacologic support or MCS. BiV failure defined as right atrial pressure (RA) ≥ 10 mmHg and pulmonary capillary wedge pressure (PCWP) ≥ 15 mmHg, LV failure as (PCWP) ≥ 15 mmHg, RV failure as RA ≥ 10 mmHg. Patient demographics, medical comorbidities, hemodynamics and survival were recorded. Results: Twenty five patients (89%) had biV failure, two had isolated LV and one RV failure. Causes of biV failure included acute MI (11), chronic cardiomyopathy (11), VT after revascularized MI (1), acute PE (1) and newly diagnosed ischemic cardiomyopathy (1). Of biV failure patients undergoing percutaneous MCS, only one received biventricular support (simultaneous Tandem, Protek Duo)