Decoupling of Hemodynamics and Congestive Symptoms in Obese Patients With Heart Failure.

BACKGROUND: Prior studies indicate significant physiological differences between obese and nonobese patients with heart failure (HF), but none have evaluated differences in hemodynamic patterns in these patient populations during treatment for acute decompensated HF (ADHF). OBJECTIVES: In this study, we assessed differences in hemodynamic trends between obese and nonobese patients during treatment for ADHF. METHODS: Obese (body mass index (BMI) >30, n = 63) and nonobese (BMI < 25, n = 69) patients with ADHF in the Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness (ESCAPE) study who had pulmonary artery catheterization data available through the duration of treatment were evaluated. Hemodynamics were analyzed at baseline and optimal day. Changes in BNP levels, weight, creatinine, BUN, 6MWT, orthopnea and dyspnea scores were assessed. RESULTS: Despite similar baseline hemodynamics, obese patients had significantly less absolute and relative pulmonary arterial wedge pressure (PAWP) reduction (-16 ± 28 vs -32 ± 29%; P = 0.03) during treatment. Obese patients also had higher PAWPs (19.9 + 8 vs 15.5 + 6.8 mmHg; P = 0.01) and PA pressures at optimization compared with nonobese patients. Obese and nonobese patients had similar relative improvements in weight, BNP, 6-minute walk test distance, dyspnea and orthopnea scores, and similar changes in creatinine and BUN levels. CONCLUSIONS: Obese patients treated for ADHF display less reduction in invasively measured left heart filling pressures, despite similar improvements in symptoms, weight loss, and noninvasive surrogates of congestion. Our findings suggest a degree of decoupling between left heart filling pressures and congestive symptoms in obese patients undergoing treatment for ADHF.

Diagnosis of Heart Failure With Preserved Ejection Fraction Among Patients With Unexplained Dyspnea.

Importance: Diagnosis of heart failure with preserved ejection fraction (HFpEF) among dyspneic patients without overt congestion is challenging. Multiple diagnostic approaches have been proposed but are not well validated against the independent gold standard for HFpEF diagnosis of an elevated pulmonary capillary wedge pressure (PCWP) during exercise. Objective: To evaluate H2FPEF and HFA-PEFF scores and a PCWP/cardiac output (CO) slope of more than 2 mm Hg/L/min to diagnose HFpEF. Design, Setting, and Participants: This retrospective case-control study included patients with unexplained dyspnea from 6 centers in the US, the Netherlands, Denmark, and Australia from March 2016 to October 2020. Diagnosis of HFpEF (cases) was definitively ascertained by the presence of elevated PCWP during exertion; control individuals were those with normal rest and exercise hemodynamics. Main Outcomes and Measures: Logistic regression was used to evaluate the accuracy of HFA-PEFF and H2FPEF scores to discriminate patients with HFpEF from controls. Results: Among 736 patients, 563 (76%) were diagnosed with HFpEF (mean [SD] age, 69 [11] years; 334 [59%] female) and 173 (24%) represented controls (mean [SD] age, 60 [15] years; 109 [63%] female). H2FPEF and HFA-PEFF scores discriminated patients with HFpEF from controls, but the H2FPEF score had greater area under the curve (0.845; 95% CI, 0.810-0.875) compared with the HFA-PEFF score (0.710; 95% CI, 0.659-0.756) (difference, -0.134; 95% CI, -0.177 to -0.094; P < .001). Specificity was robust for both scores, but sensitivity was poorer for HFA-PEFF, with a false-negative rate of 55% for low-probability scores compared with 25% using the H2FPEF score. Use of the PCWP/CO slope to redefine HFpEF rather than exercise PCWP reclassified 20% (117 of 583) of patients, but patients reclassified from HFpEF to control by this metric had clinical, echocardiographic, and hemodynamic features typical of HFpEF, including elevated resting PCWP in 66% (46 of 70) of reclassified patients. Conclusions and Relevance: In this case-control study, despite requiring fewer data, the H2FPEF score had superior diagnostic performance compared with the HFA-PEFF score and PCWP/CO slope in the evaluation of unexplained dyspnea and HFpEF in the outpatient setting.

Emerging Research on the Implications of Hormone Replacement Therapy on Coronary Heart Disease.

PURPOSE OF REVIEW: Cardiovascular disease (CVD) is known to be an increasing cause of mortality among women, particularly postmenopausal women. Hormone replacement therapy (HRT) is a topic that has been investigated over the past decade for its known impact on the cardiovascular system. This review summarizes the evidence and current opinion on the associations between HRT and CVD, evidence both supporting and against HRT use as a prevention to the development of coronary heart disease (CHD). RECENT FINDINGS: The majority of the new data available suggests the use of HRT has the potential to be more beneficial in the prevention of CVD if started in women at younger ages. Current studies also suggest that while starting HRT in older postmenopausal women may be associated with an initial slight increase in CVD, the overall lifetime occurrence rate is not increased. Several studies have also started to use the "timing hypothesis" to suggest that HRT initiated soon after menopause has the potential of being the greatest cardiovascular benefit to the patient. Overall, the data support the finding that HRT should be used only for symptomatic treatment, not in an attempt to slow progression of CVD. Current evidence does not support the use of HRT for either primary or secondary prevention of CHD. HRT has different implications based on the temporal relationship in which it is initiated in relation to the onset of menopause. Overall, the use of HRT should be an individualized decision with each patient on the basis of the individual's symptoms and overall risk profile.

Increasing efficacy and reducing side effects in treatment of chronic anal fissures: A study of topical diazepam therapy.

This is a single institution nonexperimental study intended to analyze the therapeutic efficacy of topical diazepam in treating symptoms of chronic anal fissures.Anal fissures are a common cause of anal pain. Conventional treatments include nonsteroidal anti-inflammatory drugs, topical creams, such as nitroglycerin and nifedipine, and surgery. However, these treatments are usually suboptimally efficacious or have deterring side effects.Patients at an outpatient community center with a diagnosis of a chronic anal fissure were prescribed either topical 2% (n = 19) or 4% (n = 18) diazepam cream between January 2013 and February 2015. We retrospectively analyzed their responses to treatment.All 19 patients using 2% diazepam cream experienced a positive response in pain, whereas 47.4% experienced a complete response, with a numerical rating scale (NRS) score of 0 (0-10). Eighty-eight percent of patients using 4% dose had a positive response in pain, whereas 23.5% experienced a complete response. Ninety-four percent of patients using 2% dose had a positive response in anal bleeding, whereas 68.8% experienced a complete response with an anal bleeding score (ABS) of 2 (2-9). Ninety-four percent of patients using 4% dose had a positive response in anal bleeding, whereas 64.7% experienced a complete response. Only 1 patient reported a side effect from diazepam cream-perianal pruritus.Both 2% and 4% topical diazepam provided significant pain and bleeding relief from chronic anal fissures that were refractory to conventional therapies. There were insignificant differences when assessing independent comparisons for pain and bleeding between the doses.