Non-ischaemic cardiomyopathy, sudden death and implantable defibrillators: a review and meta-analysis

Objective: The recent Danish Study to Assess the Efficacy of ICDs in Patients with Non-ischemic Systolic Heart Failure on Mortality (DANISH) trial suggested that implantable cardioverter defibrillators (ICDs) do not reduce overall mortality in patients with non-ischaemic cardiomyopathy (NICM), despite reducing sudden cardiac death. We performed an updated meta-analysis to examine the impact of ICD therapy on mortality in NICM patients. Methods: A systematic search for studies that examined the effect of ICDs on outcomes in NICM was performed. Our analysis compared patients randomised to an ICD with those randomised to no ICD, and examined the endpoint of overall mortality. Results: Six primary prevention trials and two secondary prevention trials were identified that met the pre-specified search criteria. Using a fixed-effects model, analysis of primary prevention trials revealed a reduction in overall mortality with ICD therapy (RR 0.76, 95% CI 0.65 to 0.91). Conclusions: Although our updated meta-analysis demonstrates a survival benefit of ICD therapy, the effect is substantively weakened by the inclusion of the DANISH trial—which is both the largest and most recent of the analysed trials—indicating that the residual pooled benefit of ICDs may reflect the risk of sudden death in older trials which included patients treated sub-optimally by contemporary standards. As such, these data must be interpreted cautiously. The results of the DANISH trial emphasise that there is no ‘one size fits all’ indication for primary prevention ICDs in NICM patients, and clinicians must consider age and comorbidity on an individual basis when determining whether a defibrillator is appropriate

Who benefits from a defibrillator—balancing the risk of sudden versus non-sudden death

Purpose of Review: Treatment with a defibrillator can reduce the risk of sudden death by terminating ventricular arrhythmias. The identification of patient groups in whom this function reduces overall mortality is challenging. In this review, we summarise the evidence for who benefits from a defibrillator. Recent Findings: Recent evidence suggests that contemporary pharmacologic and non-defibrillator device therapies are altering the potential risks and benefits of a defibrillator. Summary: Who benefits from a defibrillator is determined by both the risk of sudden death and the competing risk of other, non-sudden causes of death. The balance of these risks is changing, which calls into question whether historic evidence for the use of defibrillators remains robust in the modern era

Anticoagulation therapy in heart failure and sinus rhythm: a systematic review and meta-analysis

Objective: Heart failure is a prothrombotic state, and it has been hypothesised that thrombosis and embolism cause non-fatal and fatal events in heart failure and reduced ejection fraction (HFrEF). We sought to determine the effect of anticoagulant therapy on clinical outcomes in patients with HFrEF who are in sinus rhythm. Methods: We conducted an updated systematic review and meta-analysis to examine the effect of anticoagulation therapy in patients with HFrEF in sinus rhythm. Our analysis compared patients randomised to anticoagulant therapy with those randomised to antiplatelet therapy, placebo or control, and examined the endpoints of all-cause mortality, (re)hospitalisation for worsening heart failure, non-fatal myocardial infarction, non-fatal stroke of any aetiology and major haemorrhage. Results: Five trials were identified that met the prespecified search criteria. Compared with control therapy, anticoagulant treatment did not reduce all-cause mortality (risk ratio [RR] 0.99, 95% CI 0.90 to 1.08), (re)hospitalisation for heart failure (RR 0.97, 95% CI 0.82 to 1.13) or non-fatal myocardial infarction (RR 0.92, 95% CI 0.75 to 1.13). Anticoagulation did reduce the rate of non-fatal stroke (RR 0.63, 95% CI 0.49 to 0.81, p=0.001), but this was offset by an increase in the incidence of major haemorrhage (RR 1.88, 95% CI 1.49 to 2.38, p=0.001). Conclusions: Our meta-analysis provides evidence to oppose the hypothesis that thrombosis or embolism plays an important role in the morbidity and mortality associated with HFrEF, with the exception of stroke-related morbidity

Safe introduction of ventricular assist devices into national clinical practice

IntroductionWe report the first national Scottish experience with ventricularassist- devices (VADs) in a selected group of patients for whom short-term VADs (ST-VADs) were used as a salvage ‘bridge-to-decision’ (BTD) and long-term VADs (LT-VADs) as a ‘bridge-to-transplantation/recovery’ (BTT/BTR). Method: From January 2010–July 2012, 13 (mean-age 42.4(16–62) years) INTERMACS I patients required emergency ST-VAD support as BTD and 9 (meanage 35.4(16-53) years) INTERMACS I–IV required LT-VADs as BTT/BTR.ResultsOf BTD patients, 8(61.5%) received ST-BiVADs, 3(23.1%) ST-LVADs and 2(15.4%) peripheral CentriMag ECMO. Nine(69.2%) survived to last follow-up: 1(7.7%) is on ST-VAD support, 5(45.5%) bridged to myocardial-recovery and VADexplantation, 1(9.1%) to transplantation and 2(9.1%) to LT-support. Mean durations of ST-support, renal-support and postoperative ICU-stay were 31.3(2–110), 6.6(0–31) and 35.5(1–119) days, respectively. Four(36.4%) early deaths and one after discharge. One(7.7%) stroke, 2(15.4%) acute-limb-ischemia and 6(46.2%) re-explored. No driveline-infections or device-failures. Cumulative survival was 57.1% at 4, 12 and 24 months postoperatively. Of LT-LVAD patients, 6(66.7%) remain on LT-support, 1(11.1%) bridged to myocardial-recovery and VAD-explantation, and another to transplantation. Mean postoperative ICU-stay and LT-support were 19.9(6–56) and 251.3(21–751) days, respectively. One(1.11%) patient demised after 98 days of support, 2(22.2%) suffered LVAD-induced RV failure, 2(22.2%) required re-exploration for bleeding and only one(11.1%) minor superficial driveline-infection was encountered but no device/pump failure, infection or thrombosis. Cumulative survival was 85.7% at 4, 12 and 24 months of support.ConclusionWith undue vigilance, complex VAD-therapy can be integrated safely into a national program, treating the most deranged advanced-heart-failure patients, with low rates of complications and high rates of myocardial-recovery

Palliative care needs in patients hospitalized with heart failure (PCHF) study: rationale and design

Abstract Aims The primary aim of this study is to provide data to inform the design of a randomized controlled clinical trial (RCT) of a palliative care (PC) intervention in heart failure (HF). We will identify an appropriate study population with a high prevalence of PC needs defined using quantifiable measures. We will also identify which components a specific and targeted PC intervention in HF should include and attempt to define the most relevant trial outcomes. Methods An unselected, prospective, near-consecutive, cohort of patients admitted to hospital with acute decompensated HF will be enrolled over a 2-year period. All potential participants will be screened using B-type natriuretic peptide and echocardiography, and all those enrolled will be extensively characterized in terms of their HF status, comorbidity, and PC needs. Quantitative assessment of PC needs will include evaluation of general and disease-specific quality of life, mood, symptom burden, caregiver burden, and end of life care. Inpatient assessments will be performed and after discharge outpatient assessments will be carried out every 4 months for up to 2.5 years. Participants will be followed up for a minimum of 1 year for hospital admissions, and place and cause of death. Methods for identifying patients with HF with PC needs will be evaluated, and estimates of healthcare utilisation performed. Conclusion By assessing the prevalence of these needs, describing how these needs change over time, and evaluating how best PC needs can be identified, we will provide the foundation for designing an RCT of a PC intervention in HF

New science on the Open Science Grid

The Open Science Grid (OSG) includes work to enable new science, new scientists, and new modalities in support of computationally based research. There are frequently significant sociological and organizational changes required in transformation from the existing to the new. OSG leverages its deliverables to the large-scale physics experiment member communities to benefit new communities at all scales through activities in education, engagement, and the distributed facility. This paper gives both a brief general description and specific examples of new science enabled on the OSG. More information is available at the OSG web site: www.opensciencegrid.org

Psycho-social factors influencing forest conservation intentions on the agricultural frontier

Remnant forest fragments are critical to conserve biological diversity yet these are lost rapidly in areas under agricultural expansion. Conservation planning and policy require a deeper understanding of the psycho-social factors influencing landholders’ intentions towards conserving forest fragments. We surveyed 89 landholders in an agricultural frontier of the South American Gran Chaco and employed survey data to test three social psychological models: the Theory of Planned Behavior (TPB) and two modified versions of it, one integrated to the Norm Activation Theory (TPB-NAT) and one including the effect of identity (TPB-NAT-Identity). The TPB was the most parsimonious model and explained a large variance of conservation intentions (41%). Social norms and attitudes had the largest direct influence on intentions across the three models, and identity had a significant role in shaping social norms and attitudes. Interventions aimed at building social capital within landholder networks provide the best hope for influencing pro-conservation norms.Fil: Mastrangelo, Matias Enrique. Victoria University of Wellington; Nueva Zelanda. Instituto Nacional de Tecnología Agropecuaria; Argentina. Universidad Nacional de Mar del Plata. Facultad de Ciencias Agrarias; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; ArgentinaFil: Gavin, Michael C.. Colorado State University; Estados Unidos. Victoria University of Wellington; Nueva ZelandaFil: Laterra, Pedro. Universidad Nacional de Mar del Plata. Facultad de Ciencias Agrarias; Argentina. Instituto Nacional de Tecnología Agropecuaria; ArgentinaFil: Linklater, Wayne L.. Victoria University of Wellington; Nueva ZelandaFil: Milfont, Taciano L.. Victoria University of Wellington; Nueva Zeland

Budget Processes: Theory and Experimental Evidence

This paper studies budget processes, both theoretically and experimentally. We compare the outcomes of bottom-up and top-down budget processes. It is often presumed that a top-down budget process leads to a smaller overall budget than a bottom-up budget process. Ferejohn and Krehbiel (1987) showed theoretically that this need not be the case. We test experimentally the theoretical predictions of their work. The evidence from these experiments lends strong support to their theory, both at the aggregate and the individual subject level

Efficacy of implantable haemodynamic monitoring in heart failure across ranges of ejection fraction: a systematic review and meta-analysis

Aims: We conducted a meta-analysis of randomised controlled trials (RCTs) of implantable haemodynamic monitoring (IHM)-guided care. Methods: PubMed and Ovid MEDLINE were searched for RCTs of IHM in patients with heart failure (HF). Outcomes were examined in total (first and recurrent) event analyses. Results: Five trials comparing IHM-guided care with standard care alone were identified and included 2710 patients across ejection fraction (EF) ranges. Data were available for 628 patients (23.2%) with heart failure with preserved ejection fraction (HFpEF) (EF ≥50%) and 2023 patients (74.6%) with heart failure with a reduced ejection fraction (HFrEF) (EF <50%). Chronicle, CardioMEMS and HeartPOD IHMs were used. In all patients, regardless of EF, IHM-guided care reduced total HF hospitalisations (HR 0.74, 95% CI 0.66 to 0.82) and total worsening HF events (HR 0.74, 95% CI 0.66 to 0.84). In patients with HFrEF, IHM-guided care reduced total worsening HF events (HR 0.75, 95% CI 0.66 to 0.86). The effect of IHM-guided care on total worsening HF events in patients with HFpEF was uncertain (fixed-effect model: HR 0.72, 95% CI 0.59 to 0.88; random-effects model: HR 0.60, 95% CI 0.32 to 1.14). IHM-guided care did not reduce mortality (HR 0.92, 95% CI 0.71 to 1.20). IHM-guided care reduced all-cause mortality and total worsening HF events (HR 0.80, 95% CI 0.72 to 0.88). Conclusions: In patients with HF across all EFs, IHM-guided care reduced total HF hospitalisations and worsening HF events. This benefit was consistent in patients with HFrEF but not consistent in HFpEF. Further trials with pre-specified analyses of patients with an EF of ≥50% are required. PROSPERO registration number: CRD42021253905

Multiparameter diagnostic sensor measurements in heart failure patients presenting with SARS‐CoV‐2 infection

Aims: Implantable device‐based sensor measurements including heart sounds, markers of ventilation, and thoracic impedance have been shown to predict heart failure (HF) hospitalizations. We sought to assess how these parameters changed prior to COVID‐19 (Cov‐19) and how these compared with those presenting with decompensated HF or pneumonia. Methods and results: This retrospective analysis explores patterns of changes in daily measurements by implantable sensors in 10 patients with Cov‐19 and compares these findings with those observed prior to HF (n = 88) and pneumonia (n = 12) hospitalizations from the MultiSENSE, PREEMPT‐HF, and MANAGE‐HF trials. The earliest sensor changes prior to Cov‐19 were observed in respiratory rate (6 days) and temperature (5 days). There was a three‐fold to four‐fold greater increase in respiratory rate, rapid shallow breathing index, and night heart rate compared with those presenting with HF or pneumonia. Furthermore, activity levels fell more in those presenting with Cov‐19, a change that was often sustained for some time. In contrast, there were no significant changes in 1st or 3rd heart sound (S1 and S3) amplitude in those presenting with Cov‐19 or pneumonia compared with the known changes that occur in HF decompensation. Conclusions: Multi‐sensor device diagnostics may provide early detection of Cov‐19, distinguishable from worsening HF by an extreme and fast rise in respiratory rate along with no changes in S3