Omecamtiv mecarbil in chronic heart failure with reduced ejection fraction, GALACTIC‐HF: baseline characteristics and comparison with contemporary clinical trials

Aims: The safety and efficacy of the novel selective cardiac myosin activator, omecamtiv mecarbil, in patients with heart failure with reduced ejection fraction (HFrEF) is tested in the Global Approach to Lowering Adverse Cardiac outcomes Through Improving Contractility in Heart Failure (GALACTIC‐HF) trial. Here we describe the baseline characteristics of participants in GALACTIC‐HF and how these compare with other contemporary trials. Methods and Results: Adults with established HFrEF, New York Heart Association functional class (NYHA) ≥ II, EF ≤35%, elevated natriuretic peptides and either current hospitalization for HF or history of hospitalization/ emergency department visit for HF within a year were randomized to either placebo or omecamtiv mecarbil (pharmacokinetic‐guided dosing: 25, 37.5 or 50 mg bid). 8256 patients [male (79%), non‐white (22%), mean age 65 years] were enrolled with a mean EF 27%, ischemic etiology in 54%, NYHA II 53% and III/IV 47%, and median NT‐proBNP 1971 pg/mL. HF therapies at baseline were among the most effectively employed in contemporary HF trials. GALACTIC‐HF randomized patients representative of recent HF registries and trials with substantial numbers of patients also having characteristics understudied in previous trials including more from North America (n = 1386), enrolled as inpatients (n = 2084), systolic blood pressure < 100 mmHg (n = 1127), estimated glomerular filtration rate < 30 mL/min/1.73 m2 (n = 528), and treated with sacubitril‐valsartan at baseline (n = 1594). Conclusions: GALACTIC‐HF enrolled a well‐treated, high‐risk population from both inpatient and outpatient settings, which will provide a definitive evaluation of the efficacy and safety of this novel therapy, as well as informing its potential future implementation

Double Jeopardy : Acute myocardial infarction complicated by cardiogenic shock and contrast mediated anaphylactoid reaction

A 63 year-old woman who developed a severe anaphylactoidreaction to iodinated contrast in the setting of emergent percutaneous intervention(PCI) for a large anterior wall ST elevation myocardial infarction (STEMI) resulting incardiogenic shock followed by cardiopulmonary arrest necessitating placement of the patient on the arterio-venous extra corporeal membrane oxygenation (ECMO). While anaphylactoid/anaphylactic reactions to radiocontrast agents have been well documentedin literature, the development of an anaphylactoid reaction secondary to radiocontrastmedia in the setting of an ST elevation myocardial infarction (STEMI) and resultingin cardiogenic shock has never been reported. We discuss naphylactoidreactions to contrast media occurs by non-immunologic (i.e. non IgE ) mechanisms. Premedication does not abate or prevent all types of iodinated contrastmediated reactions. However, studies have shown that premedication is effective fora cutaneous reaction to iodinated contrast media (ICM). Due to the relative excellentsafety profiles of the premedication, physicians should continue to use them prior to asuspected ICM reaction

Incidental diagnosis of interrupted aortic arch in a 72-year-old man

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Kidney Function Trajectories and Right Heart Failure Following LVAD Implantation

Background Preoperative kidney dysfunction is a risk factor for right heart failure (RHF) after implantation of a left ventricular assist device (LVAD). However, characteristic kidney function trajectories before and after post‐LVAD RHF are uncertain, so we investigated this. Methods and Results We identified individuals who received primary continuous‐flow LVAD implantation from July 1, 2014 to December 31, 2017 in the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) data set. Incident RHF was ascertained using the INTERMACS definition at 1 and 3 months and classified as transient or persistent. Kidney function trajectories before and after RHF onset, and relationships of baseline kidney function with RHF risk at the different time points, were assessed. We identified 8076 LVAD recipients who met inclusion criteria. Incident RHF was present at 1 month in 26.4%. There were 4850 individuals with follow‐up at 3 months, with incident RHF in 4.2%. Kidney function trajectories differed from pre‐LVAD implantation to 1‐month follow‐up by RHF category, with those developing persistent RHF having no improvement in baseline kidney function. For trajectories before the 3‐month RHF ascertainment time, the shape was similar for those with and without RHF, with lower estimated glomerular filtration rate levels among those who developed RHF. Baseline estimated glomerular filtration rate levels below the normal range were associated with higher risk of RHF at 1 and 3 months. Conclusions In LVAD recipients, preimplantation kidney function and subsequent kidney function trajectories differed substantially by RHF at 1 and 3 months postimplantation, even after adjustment for several confounders. This may demonstrate bidirectional associations between kidney function and right ventricular function in LVAD recipients