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Prevalence of Bladder Dysfunction in Acute Decompensated Heart Failure
The 23rd Annual Scientific Meeting HFSA
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177 Prevalence of Bladder Dysfunction in Acute Decompensated Heart Failure A. Thomas, N. Gomez, B. Stewart, J. Barnett, E. Wycallis, M. Pattoli, G. Struyk, P. Shamlian, J. Fleming, P. Raghavendra, D. Mahoney, J. Ivey-Miranda, M. Griffin, V. Rao, J. Testani; Yale University School of Medicine, New Haven, CT Background: The primary therapeutic objective during the treatment of acute decompensated heart failure (ADHF) is relief from volume overload. This is achieved primarily through urinary losses of sodium and water from diuretics. Urine output is a primary source of data for monitoring and titrating therapy in these patients. To our knowledge, the prevalence and natural history of bladder dysfunction in patients with ADHF undergoing diuresis has not been described. Hypothesis: Bladder dysfunction will be common among patients with ADHF. Methods: Patients admitted to Yale New Haven hospital with worsening heart failure requiring IV diuresis were prospectively enrolled. After a forced void, bladder ultrasounds were conducted using a VerathonÒ BVI 3000 bladder scanner. Three values were taken for each patient and averaged. In a subset of these patients, an ambulatory outpatient follow-up bladder scan was performed. Results: 283 patients were enrolled and underwent determination of post void residual (PVR) volume. The average PVR volume was 131 § 169 ml. Only 41% of patients had a normal PVR (<50 ml); 43% had a PVR >100 ml and 23% of the patients had a PVR greater than 200 ml, which meets criteria for acute urinary retention. Surprisingly, we did not find a significant difference in the PVR retention volume between men (138 § 166 ml) and women (118 § 173 ml; p=0.32). There was also no difference in the prevalence of a PVR greater than 200 ml between men and women (p=0.19). Similarly, age and diabetic status were not correlated with PVR (p=NS for both) and in patients with a PVR >200 ml both the age (65 § 15 years vs. 64 § 13 years, p=0.62) and odds of having diabetes (OR=1.1, p=0.78) were not different. A total of 106 patients returned for an ambulatory a median of 43 days after discharge and had a repeat determination of PVR. Notably, there was a significant improvement in PVR volume post discharge with a mean 58 § 134 ml (p<0.001) improvement. Notably, 22% of the patients that returned for outpatient follow-up had a PVR > 200 ml while hospitalized but only 4.7% had a PVR>200 ml at the return visit. Conclusion: Significant bladder dysfunction is highly prevalent in ADHF patients and was not associated with traditional causes for bladder dysfunction. This dysfunction was largely resolved upon outpatient follow-up. Additional research is needed to understand the cause and clinical implications of the high rate of bladder dysfunction in patients with ADHF.
178 New Onset Atrial Fibrillation Following Left Ventricular Assist Device Placement is Not Associated with Increased One Year Mortality Vincenzo Trovato1, Mohamed H. Derbala1,2,3, Aaron Guo3, Sakima A. Smith1,2,3; 1 The Ohio State University Wexner Medical Center, Columbus, OH; 2The Ohio State University College of Medicine, Columbus, OH; 3Dorothy M. Davis Heart and Lung Research Institute, Columbus, OH Background: Based on current literature, the impact of atrial fibrillation (AF) on patients undergoing left ventricular assist device (LVAD) placement is unclear. Therefore, we sought to investigate the effect of AF on mortality, as well as right ventricle (RV) failure and stroke. Hypothesis: AF will increase mortality and stroke risk after LVAD placement. Methods: 296 patients who received a HeartMate II or
Figure 1. A prior history of AF is associated with significant decrease in survival at one year following LVAD implantation.
Figure 2. New onset of AF following LVAD implantation is not associated with significant difference in survival at one year.
HeartWare LVAD between 6/29/2006 and 12/29/2016 and care at The Ohio State University Medical Center were included in this study. Patients were stratified based on presence of AF before and after LVAD placement and compared via t-test based on demographics, major comorbidities and other post-LVAD complications. Additionally, a survival analysis was performed to assess for mortality associated with AF. Results: Comparing patients who developed AF after LVAD placement and those who did not, there were no significant differences in baseline demographics, including age, sex or BMI, regardless of prior AF history. Survival analysis found that a history of AF prior to LVAD placement increased the hazard of mortality nearly 2-fold (HR 1.9, 95% CI [1.2-3.1], p=0.006) (Figure 1). However, new AF following LVAD placement did not demonstrate a significant difference in survival at one year (p=0.41) (Figure 2). In addition, patients with new AF after LVAD placement did not demonstrate a significant difference in the incidence of RV failure (p=0.27) or ischemic stroke (p=1) compared to those who did not. Similarly, there was no significant difference in incidence of RV failure (p=1) and ischemic stroke (p=0.34) after LVAD placement in patients with pre-existing AF. Conclusions: Our study found that a history of AF is associated with increased mortality at one year following LVAD placement. However, onset of AF after LVAD placement was not associated with increased one-year mortality, and was not associated with increased RV failure or stroke risk. While these findings could impact management and risk stratification of LVAD patients, further research is required for validation in larger cohorts.
179 Heart Failure Guidelines are Evidence-Based, but are They Patient-Centered? Ozan Unlu1, Peter Kennel1, Ross Schumacher2, Lauren Gilstrap3, Matthew S. Maurer4, Michael W. Rich5, Anil Makam6, Parag Goyal1; 1Weill Cornell Medicine, New York, NY; 2University of Texas Southwestern Medical Center, Texas, NY; 3Dartmouth Geisel School of Medicine, Hanover, NH; 4Columbia University, New York, NY; 5Washington University School of Medicine, St Louis, MO; 6University of California San Francisco, San Francisco, CA Introduction: To apply evidence-based medicine (EBM) to individual patients and implement shared decision-making, it is necessary for clinical practice guidelines (CPGs) to incorporate performance metrics for diagnostic studies and therapeutic interventions, as well as relevant patient contexts. This is especially important in heart failure (HF), which is a highly heterogeneous population with a high prevalence of multimorbidity, and impairments in other domains (e.g. function and cognition) that can significantly impact the value of diagnostic studies and therapeutic interventions. We sought to determine the extent to which performance metrics and patient context are incorporated into major HF CPGs. Methods: We reviewed the main and supplementary documents of 2013 American College of Cardiology Foundation/American Heart Association (ACCF/AHA) CPG, 2017 ACCF/AHA/HFSA update, and 2016 European Society of Cardiology (ESC) CPG. We assessed the following domains from each recommendation: performance metrics including sensitivity/specificity, positive/negative predictive value, number needed to treat, absolute benefit/harm, and time horizon to benefit; and patient context, including comorbidity, socio-personal milieu, personal preferences, and life expectancy. Results: We examined 169 recommendations from the 2013 ACCF/AHA CPG and 2017 update, and 187
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177 Prevalence of Bladder Dysfunction in Acute Decompensated Heart Failure A. Thomas, N. Gomez, B. Stewart, J. Barnett, E. Wycallis, M. Pattoli, G. Struyk, P. Shamlian, J. Fleming, P. Raghavendra, D. Mahoney, J. Ivey-Miranda, M. Griffin, V. Rao, J. Testani; Yale University School of Medicine, New Haven, CT Background: The primary therapeutic objective during the treatment of acute decompensated heart failure (ADHF) is relief from volume overload. This is achieved primarily through urinary losses of sodium and water from diuretics. Urine output is a primary source of data for monitoring and titrating therapy in these patients. To our knowledge, the prevalence and natural history of bladder dysfunction in patients with ADHF undergoing diuresis has not been described. Hypothesis: Bladder dysfunction will be common among patients with ADHF. Methods: Patients admitted to Yale New Haven hospital with worsening heart failure requiring IV diuresis were prospectively enrolled. After a forced void, bladder ultrasounds were conducted using a VerathonÒ BVI 3000 bladder scanner. Three values were taken for each patient and averaged. In a subset of these patients, an ambulatory outpatient follow-up bladder scan was performed. Results: 283 patients were enrolled and underwent determination of post void residual (PVR) volume. The average PVR volume was 131 § 169 ml. Only 41% of patients had a normal PVR (<50 ml); 43% had a PVR >100 ml and 23% of the patients had a PVR greater than 200 ml, which meets criteria for acute urinary retention. Surprisingly, we did not find a significant difference in the PVR retention volume between men (138 § 166 ml) and women (118 § 173 ml; p=0.32). There was also no difference in the prevalence of a PVR greater than 200 ml between men and women (p=0.19). Similarly, age and diabetic status were not correlated with PVR (p=NS for both) and in patients with a PVR >200 ml both the age (65 § 15 years vs. 64 § 13 years, p=0.62) and odds of having diabetes (OR=1.1, p=0.78) were not different. A total of 106 patients returned for an ambulatory a median of 43 days after discharge and had a repeat determination of PVR. Notably, there was a significant improvement in PVR volume post discharge with a mean 58 § 134 ml (p<0.001) improvement. Notably, 22% of the patients that returned for outpatient follow-up had a PVR > 200 ml while hospitalized but only 4.7% had a PVR>200 ml at the return visit. Conclusion: Significant bladder dysfunction is highly prevalent in ADHF patients and was not associated with traditional causes for bladder dysfunction. This dysfunction was largely resolved upon outpatient follow-up. Additional research is needed to understand the cause and clinical implications of the high rate of bladder dysfunction in patients with ADHF.
178 New Onset Atrial Fibrillation Following Left Ventricular Assist Device Placement is Not Associated with Increased One Year Mortality Vincenzo Trovato1, Mohamed H. Derbala1,2,3, Aaron Guo3, Sakima A. Smith1,2,3; 1 The Ohio State University Wexner Medical Center, Columbus, OH; 2The Ohio State University College of Medicine, Columbus, OH; 3Dorothy M. Davis Heart and Lung Research Institute, Columbus, OH Background: Based on current literature, the impact of atrial fibrillation (AF) on patients undergoing left ventricular assist device (LVAD) placement is unclear. Therefore, we sought to investigate the effect of AF on mortality, as well as right ventricle (RV) failure and stroke. Hypothesis: AF will increase mortality and stroke risk after LVAD placement. Methods: 296 patients who received a HeartMate II or
Figure 1. A prior history of AF is associated with significant decrease in survival at one year following LVAD implantation.
Figure 2. New onset of AF following LVAD implantation is not associated with significant difference in survival at one year.
HeartWare LVAD between 6/29/2006 and 12/29/2016 and care at The Ohio State University Medical Center were included in this study. Patients were stratified based on presence of AF before and after LVAD placement and compared via t-test based on demographics, major comorbidities and other post-LVAD complications. Additionally, a survival analysis was performed to assess for mortality associated with AF. Results: Comparing patients who developed AF after LVAD placement and those who did not, there were no significant differences in baseline demographics, including age, sex or BMI, regardless of prior AF history. Survival analysis found that a history of AF prior to LVAD placement increased the hazard of mortality nearly 2-fold (HR 1.9, 95% CI [1.2-3.1], p=0.006) (Figure 1). However, new AF following LVAD placement did not demonstrate a significant difference in survival at one year (p=0.41) (Figure 2). In addition, patients with new AF after LVAD placement did not demonstrate a significant difference in the incidence of RV failure (p=0.27) or ischemic stroke (p=1) compared to those who did not. Similarly, there was no significant difference in incidence of RV failure (p=1) and ischemic stroke (p=0.34) after LVAD placement in patients with pre-existing AF. Conclusions: Our study found that a history of AF is associated with increased mortality at one year following LVAD placement. However, onset of AF after LVAD placement was not associated with increased one-year mortality, and was not associated with increased RV failure or stroke risk. While these findings could impact management and risk stratification of LVAD patients, further research is required for validation in larger cohorts.
179 Heart Failure Guidelines are Evidence-Based, but are They Patient-Centered? Ozan Unlu1, Peter Kennel1, Ross Schumacher2, Lauren Gilstrap3, Matthew S. Maurer4, Michael W. Rich5, Anil Makam6, Parag Goyal1; 1Weill Cornell Medicine, New York, NY; 2University of Texas Southwestern Medical Center, Texas, NY; 3Dartmouth Geisel School of Medicine, Hanover, NH; 4Columbia University, New York, NY; 5Washington University School of Medicine, St Louis, MO; 6University of California San Francisco, San Francisco, CA Introduction: To apply evidence-based medicine (EBM) to individual patients and implement shared decision-making, it is necessary for clinical practice guidelines (CPGs) to incorporate performance metrics for diagnostic studies and therapeutic interventions, as well as relevant patient contexts. This is especially important in heart failure (HF), which is a highly heterogeneous population with a high prevalence of multimorbidity, and impairments in other domains (e.g. function and cognition) that can significantly impact the value of diagnostic studies and therapeutic interventions. We sought to determine the extent to which performance metrics and patient context are incorporated into major HF CPGs. Methods: We reviewed the main and supplementary documents of 2013 American College of Cardiology Foundation/American Heart Association (ACCF/AHA) CPG, 2017 ACCF/AHA/HFSA update, and 2016 European Society of Cardiology (ESC) CPG. We assessed the following domains from each recommendation: performance metrics including sensitivity/specificity, positive/negative predictive value, number needed to treat, absolute benefit/harm, and time horizon to benefit; and patient context, including comorbidity, socio-personal milieu, personal preferences, and life expectancy. Results: We examined 169 recommendations from the 2013 ACCF/AHA CPG and 2017 update, and 187