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Diastolic Dysfunction among HIV Infected African American Population
The 21st Annual Scientific Meeting
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HFSA
S55
142
144
Ambulatory Inotrope Infusion in Advanced Heart Failure: A Systematic Review Tiana Nizamic1, M. Hassan Murad2, Larry A. Allen1, Colleen K. McIlvennan1, Daniel D. Matlock1, Sara E. Wordingham3, Shannon M. Dunlay2; 1University of Colorado, Denver, Colorado; 2Mayo Clinic Rochester, Rochester, Minnesota; 3Mayo Clinic Scottsdale, Scottsdale, Arizona
Palliative Care Use in Hospitalized Patients with Heart Failure: Low and Late Kismet Rasmusson, Jose Benuzillo, Donald Lappe, Colleen Roberts, Jeff McNally, Emmie Gardner, A.G. Kfoury; Intermountain Heart Institute, Salt Lake City, Utah
Background: Ambulatory intravenous inotrope infusions are sometimes offered to patients with advanced stage D heart failure (HF); however, a contemporary evidence synthesis of the relative risks and benefits of chronic outpatient inotropes infusions is lacking. Methods: We searched SCOPUS, Web of Science, Ovid EMBASE, and Ovid MEDLINE for trials and observational studies of long-term use of intravenous inotrope infusions (milrinone, dobutamine, dopamine, levosimendan) in outpatients with advanced HF. Meta-analysis was performed where appropriate using random effects models. Results: A total of 66 studies including 3587 patients (median 36 patients per study) met inclusion criteria, including 13 randomized controlled trials (RCTs), 4 nonrandomized trials, and 49 observational studies. The indication for inotropes was bridge to transplant (BTT) in 11 studies, palliative in 8 studies, a combination of BTT and palliative in 13 studies, and not specified in 34 studies. Inotropes were administered intermittently (42 studies) and continuously (30 studies). Most studies were at high risk for bias. The pooled rate of death on inotropes was 4.4 per 100 person-months follow-up (95% CI 3.5–5.5; 46 studies). There was no difference in mortality in patients treated with inotropes compared with controls (pooled RR 0.68 CI 0.40–1.17, P = .16; 9 RCTs). On average, patients treated with inotropes had an improvement of 1.2 New York Heart Association (NYHA) functional classes (95% CI 1.0–1.4, P < .001; 24 studies), and the improvement was of greater magnitude in patients treated with inotropes compared to controls (mean difference 0.6 NYHA functional classes, 95% CI 0.2–1.0, P = .002; 5 RCTs). The pooled rates of all-cause hospitalizations (15 studies), central line infection (15 studies), and ICD shocks (3 studies) on inotropes were 22.2, 4.6, and 2.4 per 100 per-months follow-up, respectively. Outpatient inotropes were costsaving compared to ongoing hospitalization while awaiting cardiac transplantation (5 studies) but no studies compared costs of outpatient inotropes as palliation with other strategies such as hospice. Studies comparing patients on inotropes with controls were too limited to draw conclusions on outcomes including quality of life, hospitalization, and ventricular arrhythmias. Conclusion: High-quality evidence about the risks and benefits of ambulatory inotropes infusions in patients with advanced HF is limited, particularly when used for palliation. While available data suggest that outpatient inotrope infusions are associated with improvement in NYHA functional class with no impact on risk of death, there is insufficient evidence to determine how inotropes impact other important outcomes such as hospitalization and quality of life. RCTs or welldesigned observational studies of inotrope infusions for palliation compared with other strategies are needed.
Background: Given high morbidity and mortality in heart failure (HF), the integration of palliative care (PC) is suggested along the disease trajectory. The timing and use of PC during a HF hospitalization, however, is unclear. Therefore this analysis was completed from a large hospital system to characterize mortality trends in patients hospitalized with HF in relation to the use of PC services. Methods: This was a retrospective study through an enterprise warehouse data query of patients discharged with a primary diagnosis of HF and documentation of PC. A univariate analyses using chi-square test was followed by multivariate logistic regression. Results: From January 2015 to December 2016, 3119 hospitalizations were analyzed across Intermountain’s four largest hospitals, accounting for > 80% of HF volumes across the enterprise. See the table for demographics and results. Overall, only 224 (7.2%) had documentation of PC involvement. The average number of days from the start of palliative care to death among the 30-day mortality cases was 7.5 ± 7.4 days as compared to 74.5 ± 137.6 days for HF deaths occurring later. Patients more likely to receive a PC consult were those with APDRG major or extreme risk of mortality (OR 4.1, P < .000); ejection fraction < 40% (OR 1.8; P = .001); and age > 75 years and older (OR 1.5; P = .029). Conclusions: The use of PC in hospitalized HF patients is low, often occurring late in patients with the highest acuity. Recognizing clinical factors that add to the risk of mortality may help alert clinicians to involve PC. In keeping with national HF guidelines, strategies to partner with PC colleagues earlier in the HF trajectory are needed. Whether the timely use of PC will positively impact HF quality measures needs further study.
143 Diastolic Dysfunction among HIV Infected African American Population Puvanalingam Ayyadurai, Shiva Arjun, Rudolph Napodano, Vishak Kumar, Gayathri Kamalakannan; Bronx Lebanon Hospital Center, New York, New York Background: Cardiac involvement has been documented among HIV infection. The aim of the current study was to analyze the prevalence of cardiac dysfunction among HIV infected African American population. The aim was also to see the relation between CD4 count and the occurrence of diastolic dysfunction. Materials and Methods: 261 HIV infected African American patients who were seen in the Bronx Lebanon hospital and clinics between 2009 and 2014 were retrospectively analyzed. We reviewed the Echocardiogram of all these patients from electronic medical records. Lowest CD4 count and median CD4 count of the patient was also reviewed. Presence of hypertension, diabetes mellitus, hyperlipidemia, presence or absence of smoking; drug usage was also analyzed. Left ventricular mass index and Left ventricular mass was noted. 24 patients had incomplete data and were excluded leaving behind 237 patients. Mean age of the entire study sample was 58. Microsoft Excel 2013 was used for statistical analysis. Results: Mean lowest CD 4 count of the entire sample was 214. The prevalence of systolic dysfunction was 20% and diastolic dysfunction was 78%. Most of the diastolic dysfunction was mild. Grade 1 DD—71%.;Grade 2—22%; grade 3 DD—1% and grade 4 DD—0.5%. Mild systolic dysfunction was seen in 5%, moderate in 8% and severe in 7%. Mean right ventricular systolic pressure of the entire sample was 39. Mean Left ventricular mass index—115. Mean left ventricular mass—206. Coronary artery disease was seen in 7% of the patients. Lower CD4 count was associated with higher left ventricular mass index. (P value-.006). On multivariate analysis involving hypertension, drug use, age, coronary artery disease lower CD4 count had predicted diastolic dysfunction (pvalue- < 0.05). Conclusion: HIV infected African American patients have higher prevalence of diastolic dysfunction compared with the general population. Lower CD 4 count had predicted higher left ventricular mass index. These findings suggest HIV patients manifest mild functional and morphological cardiac manifestations which are independently associated with HIV infection. Also the prevalence of diastolic dysfunction is higher in this population ie 78% when compared to other studies which documented prevalence between 30–40%. This demonstrates HIV infected African American have more chances of diastolic dysfunction than other ethnic groups.
145 Incidence of Left Bundle Branch Block—Associated Cardiomyopathy Harsh V. Barot, Sunita Sharma, Andrew Schwartzman, Richard Patten; Lahey Hospital and Medical Center, Burlington, Massachusetts Background: The presence of left bundle branch block (LBBB) is often an indicator of primary structural or ischemic heart disease. Accordingly, patients who develop LBBB are at increased risk of heart failure and sudden cardiac death. In patients with reduced left ventricular ejection fraction (LVEF) and LBBB, cardiac resynchronization therapy (CRT) improves survival and reduces heart failure hospitalizations. Indeed, CRT can affect dramatic improvement if not normalization of LVEF in selected patients with LBBB. These observations have led to the notion that LBBB may play a causative role in the development of dilated cardiomyopathy and heart failure but the true incidence of LBBB-associated cardiomyopathy is not well established. We therefore examined the incidence of a progressive decline in LVEF among patients with an initial normal LVEF in the absence of clinically relevant coronary artery disease (CAD). Methods: We retrospectively examined records of patients with LBBB from our institution’s electrocardiogram database and identified those with an initial preserved LVEF (≥45%) without evidence of coronary artery disease (CAD) or other identifiable cause of structural heart disease. Follow up imaging and clinical information was analyzed to establish how many of these patients exhibited a significant decline in their LVEF (defined as ≤40%). Numerical data are presented as mean ± sd. Results: Among a total of 350 patients with LBBB, 94 fit our entry criteria having a mean baseline LVEF of 57 ± 6 %. The mean age of the population was 71 ± 12years. Of these 94 subjects, 13 (14%) developed a significant decline in LV systolic function to an LVEF of 31 ± 7% over a mean follow up period of 40 ± 24 months. Conclusions: These data therefore support that LBBB is associated with the development of progressive LV systolic dysfunction in the absence of CAD or other identifiable etiologies. Moreover, our data suggest that the incidence of LBBB-associated or “dyssynchrony” cardiomyopathy may be higher than previously reported in some series. Further work will be needed to examine predictive clinical variables that may aid in selecting at-risk patients who warrant longitudinal follow up along with serial assessments of LV structure and function.
•
HFSA
S55
142
144
Ambulatory Inotrope Infusion in Advanced Heart Failure: A Systematic Review Tiana Nizamic1, M. Hassan Murad2, Larry A. Allen1, Colleen K. McIlvennan1, Daniel D. Matlock1, Sara E. Wordingham3, Shannon M. Dunlay2; 1University of Colorado, Denver, Colorado; 2Mayo Clinic Rochester, Rochester, Minnesota; 3Mayo Clinic Scottsdale, Scottsdale, Arizona
Palliative Care Use in Hospitalized Patients with Heart Failure: Low and Late Kismet Rasmusson, Jose Benuzillo, Donald Lappe, Colleen Roberts, Jeff McNally, Emmie Gardner, A.G. Kfoury; Intermountain Heart Institute, Salt Lake City, Utah
Background: Ambulatory intravenous inotrope infusions are sometimes offered to patients with advanced stage D heart failure (HF); however, a contemporary evidence synthesis of the relative risks and benefits of chronic outpatient inotropes infusions is lacking. Methods: We searched SCOPUS, Web of Science, Ovid EMBASE, and Ovid MEDLINE for trials and observational studies of long-term use of intravenous inotrope infusions (milrinone, dobutamine, dopamine, levosimendan) in outpatients with advanced HF. Meta-analysis was performed where appropriate using random effects models. Results: A total of 66 studies including 3587 patients (median 36 patients per study) met inclusion criteria, including 13 randomized controlled trials (RCTs), 4 nonrandomized trials, and 49 observational studies. The indication for inotropes was bridge to transplant (BTT) in 11 studies, palliative in 8 studies, a combination of BTT and palliative in 13 studies, and not specified in 34 studies. Inotropes were administered intermittently (42 studies) and continuously (30 studies). Most studies were at high risk for bias. The pooled rate of death on inotropes was 4.4 per 100 person-months follow-up (95% CI 3.5–5.5; 46 studies). There was no difference in mortality in patients treated with inotropes compared with controls (pooled RR 0.68 CI 0.40–1.17, P = .16; 9 RCTs). On average, patients treated with inotropes had an improvement of 1.2 New York Heart Association (NYHA) functional classes (95% CI 1.0–1.4, P < .001; 24 studies), and the improvement was of greater magnitude in patients treated with inotropes compared to controls (mean difference 0.6 NYHA functional classes, 95% CI 0.2–1.0, P = .002; 5 RCTs). The pooled rates of all-cause hospitalizations (15 studies), central line infection (15 studies), and ICD shocks (3 studies) on inotropes were 22.2, 4.6, and 2.4 per 100 per-months follow-up, respectively. Outpatient inotropes were costsaving compared to ongoing hospitalization while awaiting cardiac transplantation (5 studies) but no studies compared costs of outpatient inotropes as palliation with other strategies such as hospice. Studies comparing patients on inotropes with controls were too limited to draw conclusions on outcomes including quality of life, hospitalization, and ventricular arrhythmias. Conclusion: High-quality evidence about the risks and benefits of ambulatory inotropes infusions in patients with advanced HF is limited, particularly when used for palliation. While available data suggest that outpatient inotrope infusions are associated with improvement in NYHA functional class with no impact on risk of death, there is insufficient evidence to determine how inotropes impact other important outcomes such as hospitalization and quality of life. RCTs or welldesigned observational studies of inotrope infusions for palliation compared with other strategies are needed.
Background: Given high morbidity and mortality in heart failure (HF), the integration of palliative care (PC) is suggested along the disease trajectory. The timing and use of PC during a HF hospitalization, however, is unclear. Therefore this analysis was completed from a large hospital system to characterize mortality trends in patients hospitalized with HF in relation to the use of PC services. Methods: This was a retrospective study through an enterprise warehouse data query of patients discharged with a primary diagnosis of HF and documentation of PC. A univariate analyses using chi-square test was followed by multivariate logistic regression. Results: From January 2015 to December 2016, 3119 hospitalizations were analyzed across Intermountain’s four largest hospitals, accounting for > 80% of HF volumes across the enterprise. See the table for demographics and results. Overall, only 224 (7.2%) had documentation of PC involvement. The average number of days from the start of palliative care to death among the 30-day mortality cases was 7.5 ± 7.4 days as compared to 74.5 ± 137.6 days for HF deaths occurring later. Patients more likely to receive a PC consult were those with APDRG major or extreme risk of mortality (OR 4.1, P < .000); ejection fraction < 40% (OR 1.8; P = .001); and age > 75 years and older (OR 1.5; P = .029). Conclusions: The use of PC in hospitalized HF patients is low, often occurring late in patients with the highest acuity. Recognizing clinical factors that add to the risk of mortality may help alert clinicians to involve PC. In keeping with national HF guidelines, strategies to partner with PC colleagues earlier in the HF trajectory are needed. Whether the timely use of PC will positively impact HF quality measures needs further study.
143 Diastolic Dysfunction among HIV Infected African American Population Puvanalingam Ayyadurai, Shiva Arjun, Rudolph Napodano, Vishak Kumar, Gayathri Kamalakannan; Bronx Lebanon Hospital Center, New York, New York Background: Cardiac involvement has been documented among HIV infection. The aim of the current study was to analyze the prevalence of cardiac dysfunction among HIV infected African American population. The aim was also to see the relation between CD4 count and the occurrence of diastolic dysfunction. Materials and Methods: 261 HIV infected African American patients who were seen in the Bronx Lebanon hospital and clinics between 2009 and 2014 were retrospectively analyzed. We reviewed the Echocardiogram of all these patients from electronic medical records. Lowest CD4 count and median CD4 count of the patient was also reviewed. Presence of hypertension, diabetes mellitus, hyperlipidemia, presence or absence of smoking; drug usage was also analyzed. Left ventricular mass index and Left ventricular mass was noted. 24 patients had incomplete data and were excluded leaving behind 237 patients. Mean age of the entire study sample was 58. Microsoft Excel 2013 was used for statistical analysis. Results: Mean lowest CD 4 count of the entire sample was 214. The prevalence of systolic dysfunction was 20% and diastolic dysfunction was 78%. Most of the diastolic dysfunction was mild. Grade 1 DD—71%.;Grade 2—22%; grade 3 DD—1% and grade 4 DD—0.5%. Mild systolic dysfunction was seen in 5%, moderate in 8% and severe in 7%. Mean right ventricular systolic pressure of the entire sample was 39. Mean Left ventricular mass index—115. Mean left ventricular mass—206. Coronary artery disease was seen in 7% of the patients. Lower CD4 count was associated with higher left ventricular mass index. (P value-.006). On multivariate analysis involving hypertension, drug use, age, coronary artery disease lower CD4 count had predicted diastolic dysfunction (pvalue- < 0.05). Conclusion: HIV infected African American patients have higher prevalence of diastolic dysfunction compared with the general population. Lower CD 4 count had predicted higher left ventricular mass index. These findings suggest HIV patients manifest mild functional and morphological cardiac manifestations which are independently associated with HIV infection. Also the prevalence of diastolic dysfunction is higher in this population ie 78% when compared to other studies which documented prevalence between 30–40%. This demonstrates HIV infected African American have more chances of diastolic dysfunction than other ethnic groups.
145 Incidence of Left Bundle Branch Block—Associated Cardiomyopathy Harsh V. Barot, Sunita Sharma, Andrew Schwartzman, Richard Patten; Lahey Hospital and Medical Center, Burlington, Massachusetts Background: The presence of left bundle branch block (LBBB) is often an indicator of primary structural or ischemic heart disease. Accordingly, patients who develop LBBB are at increased risk of heart failure and sudden cardiac death. In patients with reduced left ventricular ejection fraction (LVEF) and LBBB, cardiac resynchronization therapy (CRT) improves survival and reduces heart failure hospitalizations. Indeed, CRT can affect dramatic improvement if not normalization of LVEF in selected patients with LBBB. These observations have led to the notion that LBBB may play a causative role in the development of dilated cardiomyopathy and heart failure but the true incidence of LBBB-associated cardiomyopathy is not well established. We therefore examined the incidence of a progressive decline in LVEF among patients with an initial normal LVEF in the absence of clinically relevant coronary artery disease (CAD). Methods: We retrospectively examined records of patients with LBBB from our institution’s electrocardiogram database and identified those with an initial preserved LVEF (≥45%) without evidence of coronary artery disease (CAD) or other identifiable cause of structural heart disease. Follow up imaging and clinical information was analyzed to establish how many of these patients exhibited a significant decline in their LVEF (defined as ≤40%). Numerical data are presented as mean ± sd. Results: Among a total of 350 patients with LBBB, 94 fit our entry criteria having a mean baseline LVEF of 57 ± 6 %. The mean age of the population was 71 ± 12years. Of these 94 subjects, 13 (14%) developed a significant decline in LV systolic function to an LVEF of 31 ± 7% over a mean follow up period of 40 ± 24 months. Conclusions: These data therefore support that LBBB is associated with the development of progressive LV systolic dysfunction in the absence of CAD or other identifiable etiologies. Moreover, our data suggest that the incidence of LBBB-associated or “dyssynchrony” cardiomyopathy may be higher than previously reported in some series. Further work will be needed to examine predictive clinical variables that may aid in selecting at-risk patients who warrant longitudinal follow up along with serial assessments of LV structure and function.