Advanced Heart Failure Therapies and Cardiorenal Syndrome

Heart failure (HF) is extremely prevalent and for those with end-stage (stage D) disease, 1-year survival is only 25-50%. Several studies have captured the mortality impact of kidney disease on patients with HF, and measures of kidney function are a component of many HF risk stratification scores. The management of advanced HF complicated by cardiorenal syndrome (CRS) is challenging, and irreversible kidney failure often limits patient candidacy for advanced HF therapies, such as transplant or left ventricular assist device therapy. Thus, prompt institution of aggressive therapy is warranted in stage D HF patients with CRS to prevent irreversible kidney failure. In this chapter, we discuss the assessment and management of patients with CRS with end-stage HF. In addition to discussing medical therapy aimed at decongestion and increased cardiac inotropy, we provide a summary of temporary circulatory support devices that can be considered for those whom hospice is not desired. In all circumstances, a close collaboration between the advanced HF specialist and nephrologist is needed to achieve the best patient outcomes

Cardiogenic shock: A bittersweet diagnosis

Background Sweet\u27s syndrome (SS), also known as febrile neutrophilic dermatosis, is a rare reactive phenomenon characterized by a pattern of clinical symptoms with physical and pathologic manifestations. We present a case of SS with cardiac, dermatologic, and neurologic manifestations. Case A 73-year-old female presented with slurred speech for several hours, along with preceding fevers and flu-like symptoms. Initial stroke and infectious workups were negative. A transthoracic echocardiogram (TTE) was unremarkable. Two days later, she became tachypneic with pulmonary edema on chest X-ray. A repeat TTE showed an EF of 30% with global hypokinesis. A left heart catheterization revealed no obstructive coronary artery disease. She was intubated and an Impella CP was placed with Dobutamine for concerns of cardiogenic shock. She remained febrile with altered mentation despite an unremarkable infectious workup. ESR and CRP were elevated to 45mm/hr and 19.2mg/dL, respectively. WBC was elevated to 13,400 with a 92% neutrophil predominance. Several days after admission, pink papules on the patient\u27s lower extremities were discovered, biopsied, and revealed neutrophilic dermatitis with negative infectious stains. Decision-making This patient fulfilled two major criteria required for the diagnosis of SS, including the abrupt onset of painful erythematous nodules, and histopathologic evidence of dense neutrophilic infiltrate without evidence of leukocytoclastic vasculitis. She met two of the four minor criteria, including pyrexia and at least three abnormal laboratory values (elevated ESR \u3e 20mm/hr, positive CRP, \u3e8000 leukocytes, \u3e70% neutrophils). Given the fulfillment of her criteria and lack of an alternative etiology behind her shock, the patient was started on 1mg/kg of prednisone daily. She had rapid improvement in her skin papules, mentation, and cardiogenic shock, with discontinuation of her Impella CP and Dobutamine within 24 hours. Repeat TTE showed an EF of 53%. Conclusion This case highlights SS as a rare cause of cardiogenic shock and encephalitis and illustrates the importance of maintaining a broad differential diagnosis when determining the etiology of cardiogenic shock

Safety of evaluating for acute coronary syndrome in the emergency department using a modified heart score

Background Chest pain is a common complaint in the emergency department (ED). The evaluation of these patients, which commonly involves stress testing, is time-consuming and costly. Prior retrospective studies demonstrated that a modified HEART score (m-HS) which combines the traditional HS and serial high-sensitivity cardiac troponin measurements could be used to identify low risk patients for discharge from the ED without further cardiac testing. The HS combines elements of the history, cardiac risk factors, and ECG. A HS ≤ 3 is considered low risk. In this study, we evaluated the safety of implementing this concept prospectively. Methods A prospective implementation trial conducted at an ED in 2017 included adult patients who were evaluated for possible acute coronary syndrome. Patients needed to have Siemens cardiac troponin I ultra \u3c 40 ng/L (99th%) at 0 and 3 hours in addition to a HS ≤ 3 to be discharged without further testing. Thirty-day major adverse cardiovascular events (MACE) (death, acute myocardial infarction, revascularization procedure and readmission) were recorded. Results Of 422 patients, 33 were lost to follow up, resulting in 389 for analysis. The mean age was 50.6 ± 14.4. There were 161 (41.6%) male, 203 white (52.6%), 135 (35%) black and 48 (12.4%) classified as others. Baseline risk factors: 128 (33%) hypertension, 35 (9.1%) diabetes, 100 (25.8%) hyperlipidemia, 14 (3.6%) coronary artery disease, 98 (25.5%) active smoker, 25 (6.5%) with family history of cardiac disease. Among the 3 MACEs (0.8%) which were all 30-day readmissions, 2 (0.5%) were non-cardiac related while 1 (0.3%) was for atypical chest pain that was determined to be non-cardiac chest pain by cardiology consultation. This patient also had the only positive cardiac test (1.8%) (myocardial perfusion imaging with minimal ischemia) out of the 56 outpatient cardiac stress tests. Conclusion In the ED setting, m-HS is an effective tool to identify low risk patients who are safe for early discharge. At 30 days, no significant MACEs were detected and these low risk patients likely do not require stress testing

Performance of MAGGIC score in African Americans compared to whites

Background: Risk stratification is critical in Heart Failure (HF) care. The MAGGIC score is a validated tool derived from a large multi-study cohort of nearly 40,000 but very few of the patients self-identified as Black or of African Ancestry (less than 400). There is little data assessing MAGGIC score utility in African Americans (AA). Methods: This single center study analyzed a total of 4264 patients from 2 cohorts; one utilizing administrative data from hospital discharges for HF (January 1 st , 2014 through July 30 th , 2015, n = 2503) and a prospective registry of ambulatory HF patients (n = 1761), both based in southeast Michigan. Baseline characteristics were collected to tabulate MAGGIC score and test its risk stratification in self-identified African Americans (AA) and whites. The primary endpoint was time to all-cause mortality. Death was detected using system records and the social security death master file. Cox models with MAGGIC score as the only variable stratified by race, and a combined model including MAGGIC, race, and MAGGIC*race were tested. P \u3c .05 was considered significant. Results: Overall, 1748 patients (41%) were AA, and a total of 1151 (27%) patients died during follow up. MAGGIC score was strongly and similarly predictive of survival in both race groups. Among AA, each MAGGIC point carried HR of 1.12 (95%CI 1.10, 1.14; P \u3c .001) while in whites the HR was 1.13 (95%CI 1.12, 1.14; P \u3c .001). Formal test of interaction of MAGGIC by race was not significant ( P = .153). However, there was a difference in survival by race, with African Americans showing a survival advantage (HR = 0.72, P = .001) which appears to be isolated to the highest risk subgroup (Figure). Conclusion: These data support the utility of the MAGGIC score for risk stratification in African Americans who suffer from HF. However, there may still be residual differences in outcomes between AA and whites despite overall risk adjustment, particularly in highest risk subgroup

Improving risk prediction in heart failure: MAGGIC plus natriuretic peptides

Background: Risk stratification of patients with heart failure (HF) remains challenging but is a critical need. The MAGGIC score is a clinical risk model derived from meta-analysis of nearly 40k patients. Natriuretic peptides (NP) have consistently shown powerful risk prediction in HF patients, but the incremental value in addition to MAGGIC score is not known. Methods: In this single center study 4264 patients were analyzed from two cohorts; a prospective ambulatory registry of HF patients (n = 1314) who had baseline NTproBNP levels measured, and a retrospective cohort collected utilizing administrative data from hospital discharges for HF (January 1 st , 2014 through July 30 th , 2015; n = 2503) with clinical BNP levels measured at or near discharge. The hospital discharge cohort were all assigned NYHA class IV. The primary end-point was all cause mortality. Performance of the MAGGIC score and NP levels was assessed within each cohort utilizing Cox regression and receiver operating curves (ROC) analysis (MAGGIC alone vs. MAGGIC+NP) with the net reclassification improvement (NRI) also calculated. Results: The overall cohort had an average age of 71.2 years, was 47.8% females, and 41% self-identified African Americans. Median follow up was 1.52 years during which there were 1139 deaths (27%). The MAGGIC score was a strong predictor of outcome in both cohorts ( P \u3c .001). In ROC analysis of the ambulatory registry, NP significantly improved area under the curve (AUC) compared to MAGGIC alone from 0.74 to 0.79 ( P = .002) and had a NRI of 0.354 (Figure). In contrast, within the hospital discharge cohort NP levels did not significantly add to MAGGIC score (AUC 0.681 vs. 0.676, NRI = 0.033, P = .284) (Figure). Conclusion: In our study, NP levels in the ambulatory setting significantly improved risk stratification provided by the MAGGIC score, but discharge NP levels did not improve MAGGIC prediction of post-hospital survival. Overall risk stratification and particularly NP utility is much better in the ambulatory setting

Performance of the Meta-Analysis Global Group in Chronic Heart Failure Score in Black Patients Compared With Whites

BACKGROUND: Risk stratification is critical in heart failure (HF) and the Meta-Analysis Global Group in Chronic HF (MAGGIC) score is a validated tool derived from ~40,000 patients. However, few of these patients self-identified as black, raising uncertainty regarding performance in blacks with HF. METHODS AND RESULTS: This study analyzed a racially diverse group of 4046 patients (1646 black and 2400 white) from a single center from 2007 to 2015. Baseline characteristics were collected to tabulate MAGGIC score and test its discrimination and calibration within race groups. The primary end point was all-cause mortality. Death was detected using system records and the social security death master file. Discrimination was tested using Cox models of MAGGIC score stratified by race, and combined analysis including MAGGIC, race, and MAGGIC×race. Calibration was assessed using linear regression models and plots of observed versus predicted data. Overall, 901 (21%) patients died during 1-year follow-up. MAGGIC score discrimination was similar in both race groups in terms of C statistic (0.707±0.027 versus 0.725±0.014, for black versus white; P=0.556) and the hazard ratio (HR) per MAGGIC point was 1.12 in black patients (95% CI, 1.10-1.14) and 1.13 in white patients (95% CI, 1.12-1.14). Race was a significant correlate of survival, with better survival in black patients compared with white (HR, 0.66; 95% CI, 0.56-0.78), but the interaction of MAGGIC×race was not significant (β=-0.013; P=0.16), and adding race to the model did not improve discrimination (C statistic for MAGGIC versus MAGGIC+race, 0.721 versus 0.722; P=0.79). In calibration testing, the slope was not significantly different from 1 in either group, but the groups differed from each other, and it was closer to unity among black patients (0.94 versus 1.4; P=0.004). CONCLUSIONS: These data support the use of the MAGGIC score to risk stratify black patients with HF

Performance of the Meta-Analysis Global Group in Chronic Heart Failure Score in Black Patients Compared With Whites

BACKGROUND: Risk stratification is critical in heart failure (HF) and the Meta-Analysis Global Group in Chronic HF (MAGGIC) score is a validated tool derived from ~40,000 patients. However, few of these patients self-identified as black, raising uncertainty regarding performance in blacks with HF. METHODS AND RESULTS: This study analyzed a racially diverse group of 4046 patients (1646 black and 2400 white) from a single center from 2007 to 2015. Baseline characteristics were collected to tabulate MAGGIC score and test its discrimination and calibration within race groups. The primary end point was all-cause mortality. Death was detected using system records and the social security death master file. Discrimination was tested using Cox models of MAGGIC score stratified by race, and combined analysis including MAGGIC, race, and MAGGIC×race. Calibration was assessed using linear regression models and plots of observed versus predicted data. Overall, 901 (21%) patients died during 1-year follow-up. MAGGIC score discrimination was similar in both race groups in terms of C statistic (0.707±0.027 versus 0.725±0.014, for black versus white; P=0.556) and the hazard ratio (HR) per MAGGIC point was 1.12 in black patients (95% CI, 1.10-1.14) and 1.13 in white patients (95% CI, 1.12-1.14). Race was a significant correlate of survival, with better survival in black patients compared with white (HR, 0.66; 95% CI, 0.56-0.78), but the interaction of MAGGIC×race was not significant (β=-0.013; P=0.16), and adding race to the model did not improve discrimination (C statistic for MAGGIC versus MAGGIC+race, 0.721 versus 0.722; P=0.79). In calibration testing, the slope was not significantly different from 1 in either group, but the groups differed from each other, and it was closer to unity among black patients (0.94 versus 1.4; P=0.004). CONCLUSIONS: These data support the use of the MAGGIC score to risk stratify black patients with HF

Performance of the Meta-Analysis Global Group in Chronic Heart Failure Score in Black Patients Compared With Whites

BACKGROUND: Risk stratification is critical in heart failure (HF) and the Meta-Analysis Global Group in Chronic HF (MAGGIC) score is a validated tool derived from ~40,000 patients. However, few of these patients self-identified as black, raising uncertainty regarding performance in blacks with HF. METHODS AND RESULTS: This study analyzed a racially diverse group of 4046 patients (1646 black and 2400 white) from a single center from 2007 to 2015. Baseline characteristics were collected to tabulate MAGGIC score and test its discrimination and calibration within race groups. The primary end point was all-cause mortality. Death was detected using system records and the social security death master file. Discrimination was tested using Cox models of MAGGIC score stratified by race, and combined analysis including MAGGIC, race, and MAGGIC×race. Calibration was assessed using linear regression models and plots of observed versus predicted data. Overall, 901 (21%) patients died during 1-year follow-up. MAGGIC score discrimination was similar in both race groups in terms of C statistic (0.707±0.027 versus 0.725±0.014, for black versus white; P=0.556) and the hazard ratio (HR) per MAGGIC point was 1.12 in black patients (95% CI, 1.10-1.14) and 1.13 in white patients (95% CI, 1.12-1.14). Race was a significant correlate of survival, with better survival in black patients compared with white (HR, 0.66; 95% CI, 0.56-0.78), but the interaction of MAGGIC×race was not significant (β=-0.013; P=0.16), and adding race to the model did not improve discrimination (C statistic for MAGGIC versus MAGGIC+race, 0.721 versus 0.722; P=0.79). In calibration testing, the slope was not significantly different from 1 in either group, but the groups differed from each other, and it was closer to unity among black patients (0.94 versus 1.4; P=0.004). CONCLUSIONS: These data support the use of the MAGGIC score to risk stratify black patients with HF

Performance of the Meta-Analysis Global Group in Chronic Heart Failure Score in Black Patients Compared With Whites

BACKGROUND: Risk stratification is critical in heart failure (HF) and the Meta-Analysis Global Group in Chronic HF (MAGGIC) score is a validated tool derived from ~40,000 patients. However, few of these patients self-identified as black, raising uncertainty regarding performance in blacks with HF. METHODS AND RESULTS: This study analyzed a racially diverse group of 4046 patients (1646 black and 2400 white) from a single center from 2007 to 2015. Baseline characteristics were collected to tabulate MAGGIC score and test its discrimination and calibration within race groups. The primary end point was all-cause mortality. Death was detected using system records and the social security death master file. Discrimination was tested using Cox models of MAGGIC score stratified by race, and combined analysis including MAGGIC, race, and MAGGIC×race. Calibration was assessed using linear regression models and plots of observed versus predicted data. Overall, 901 (21%) patients died during 1-year follow-up. MAGGIC score discrimination was similar in both race groups in terms of C statistic (0.707±0.027 versus 0.725±0.014, for black versus white; P=0.556) and the hazard ratio (HR) per MAGGIC point was 1.12 in black patients (95% CI, 1.10-1.14) and 1.13 in white patients (95% CI, 1.12-1.14). Race was a significant correlate of survival, with better survival in black patients compared with white (HR, 0.66; 95% CI, 0.56-0.78), but the interaction of MAGGIC×race was not significant (β=-0.013; P=0.16), and adding race to the model did not improve discrimination (C statistic for MAGGIC versus MAGGIC+race, 0.721 versus 0.722; P=0.79). In calibration testing, the slope was not significantly different from 1 in either group, but the groups differed from each other, and it was closer to unity among black patients (0.94 versus 1.4; P=0.004). CONCLUSIONS: These data support the use of the MAGGIC score to risk stratify black patients with HF

Socioeconomic and Racial Disparities: a Case-Control Study of Patients Receiving Transcatheter Aortic Valve Replacement for Severe Aortic Stenosis

BACKGROUND: We sought to quantify socioeconomic disparities in patients with severe aortic stenosis (AS) undergoing transcatheter aortic valve replacement (TAVR) at an urban, tertiary referral center. METHODS: This retrospective case-control study identified 67 patients with severe AS (aortic valve [AV] area ≤1 cm RESULTS: Income disparity was significant in that with every $10,000 increase in income, the odds of receiving TAVR increased by 10% (p = 0.05). Non-blacks were significantly more likely to receive TAVR than blacks (odds ratio [OR] 2.812, confidence interval [CI] 1.007-7.853; p = 0.048). No differences in comorbidities were found between the two groups. Post hoc analysis to identify etiologies of the found disparities examined differences of AV area and AV area index, indication for two-dimensional echocardiography (echo), symptoms prior to echo, and action after echo within the control group. Black race significantly impacted the TAVR status despite the same AV area (OR 0.33, CI 0.09-0.97, p = 0.043). After echo, blacks were more likely to decline AVR, be lost to follow-up, and not be referred to cardiology (OR 4.41, CI 1.43-13.64; p = 0.010). CONCLUSION: Socioeconomic and racial disparities were associated with patients with severe AS receiving TAVR at a major referral center. This study emphasizes the importance of improving access to standard of care for these subgroups of cardiac patients