Clinical outcomes of intravenous iron therapy in patients with heart failure and iron deficiency: Meta-analysis and trial sequential analysis of randomized clinical trials.

BACKGROUND: Iron deficiency in patients with heart failure (HF) is underdiagnosed and undertreated. The role of intravenous (IV) iron is well-established to improve quality of life measures. Emerging evidence also supports its role in preventing cardiovascular events in patients with HF. METHODOLOGY: We conducted a literature search of multiple electronic databases. Randomized controlled trials that compared IV iron to usual care among patients with HF and reported cardiovascular (CV) outcomes were included. Primary outcome was the composite of first heart failure hospitalization (HFH) or CV death. Secondary outcomes included HFH (first or recurrent), CV death, all-cause mortality, hospitalization for any cause, gastrointestinal (GI) side effects, or any infection. We performed trial sequential and cumulative meta-analyses to evaluate the effect of IV iron on the primary endpoint, and on HFH. RESULTS: Nine trials enrolling 3337 patients were included. Adding IV iron to usual care significantly reduced the risk of first HFH or CV death [risk ratio (RR) 0.84; 95 % confidence interval (CI) 0.75-0.93; I2 = 0 %; number needed to treat (NNT) 18], which was primarily driven by a reduction in the risk of HFH of 25 %. IV iron also reduced the risk of the composite of hospitalization for any cause or death (RR 0.92; 95 % CI 0.85-0.99; I2 = 0 %; NNT 19). There was no significant difference in the risk of CV death, all-cause mortality, adverse GI events, or any infection among patients receiving IV iron compared to usual care. The observed benefits of IV iron were directionally consistent across trials and crossed both the statistical and trial sequential boundaries of benefit. CONCLUSION: In patients with HF and iron deficiency, the addition of IV iron to usual care reduces the risk of HFH without affecting the risk of CV or all-cause mortality.

Left Ventricular Unloading With Impella Versus IABP in Patients With VA-ECMO: A Systematic Review and Meta-Analysis.

Venoarterial extracorporeal membrane oxygenation (VA-ECMO) use for circulatory support in cardiogenic shock results in increased left ventricular (LV) afterload. The use of concomitant Impella or intra-aortic balloon pump (IABP) have been proposed as adjunct devices for LV unloading. The authors sought to compare head-to-head efficacy and safety outcomes between the 2 LV unloading strategies. We conducted a search of Medline, EMBASE, and Cochrane databases to identify studies comparing the use of Impella to IABP in patients on VA-ECMO. The primary outcome of interest was in-hospital mortality. The secondary outcomes included transition to durable LV assist devices/cardiac transplantation, stroke, limb ischemia, need for continuous renal replacement therapy, major bleeding, and hemolysis. Pooled risk ratios (RRs) with 95% confidence interval and heterogeneity statistic I2 were calculated using a random-effects model. A total of 7 observational studies with 698 patients were included. Patients on VA-ECMO unloaded with Impella vs IABP had similar risk of short-term all-cause mortality, defined as either 30-day or in-hospital mortality- 60.8% vs 64.9% (RR 0.93 [0.71 to 1.21], I2 = 71%). No significant difference was observed in transition to durable LV assist devices/cardiac transplantation, continuous renal replacement therapy initiation, stroke, or limb ischemia between the 2 strategies. However, the use of VA-ECMO with Impella was associated with increased risk of major bleeding (57.2% vs 39.7%) (RR 1.66 [1.12 to 2.44], I2 = 82%) and hemolysis (31% vs 7%) (RR 4.61 [1.24 to 17.17], I2 = 66%) compared with VA-ECMO, along with IABP. In conclusion, in patients requiring VA-ECMO for circulatory support, the concomitant use of Impella or IABP had comparable short-term mortality. However, Impella use was associated with increased risk of major bleeding and hemolysis.

The Impact of Cocaine Use and the Obesity Paradox in Patients With Heart Failure With Reduced Ejection Fraction Due to Non-ischemic Cardiomyopathy.

Background Obesity and illicit drugs are independent risk factors for developing heart failure (HF). However, recent studies have suggested that patients who already have HF and are obese have better clinical outcomes. We aim to study the effect of cocaine use on this obesity paradox phenomenon as it pertains to HF readmissions. Methodology In a retrospective chart analysis, we reviewed patients with a diagnosis of HF with reduced ejection fraction (HFrEF) admitted to Metropolitan Hospital in New York. We studied the association between body mass index (BMI) categories, namely, non-obese (<30 kg/m2) and obese (≥30 kg/m2), cocaine use, and the primary outcome (time to readmission for HF within 30 days after discharge). The interaction between cocaine and obesity status and its association with the primary outcome was also assessed. Results A total of 261 patients were identified. Non-obese status and cocaine use were associated with an increased hazard of readmission in 30 days (hazard ratio (HR) = 2.28, p = 0.049 and HR = 3.12, p = 0.004, respectively). Furthermore, cocaine users who were non-obese were over six times more likely to be re-admitted in 30 days compared to non-cocaine users who were obese (HR = 6.45, p = 0.0002). Conclusions Non-obese status and continued use of cocaine have a negative additive effect in impacting HF readmissions.

Myocardial Scintigraphy in Diagnosing Cardiac Transthyretin Amyloidosis.

Myocardial scintigraphy with technetium-99m pyrophosphate is a minimally invasive technique that can distinguish between transthyretin amyloidosis (ATTR) and light-chain amyloidosis. We present a case in which it helped determine the amyloidosis type in a 74-year-old man with cardiac amyloidosis and multiple previous admissions for acute decompensated heart failure. The patient presented with increasing abdominal girth and bilateral lower extremity edema. His medical history also included atrial fibrillation, liver cirrhosis, hypertension, stage 3 chronic kidney disease, and peripheral vascular disease. We prescribed guideline-directed medical therapy for his acute decompensated heart failure with cardiorenal syndrome and his decompensated cirrhosis. Two years previously, a presumptive diagnosis of ATTR cardiomyopathy had been made on the basis of the patient's age, predominantly cardiac involvement, an unremarkable serum protein electrophoresis result, and an abnormal free κ/λ light-chain ratio of 2.24. Over the next year, the patient's clinical condition had worsened with the development of liver cirrhosis and peripheral neuropathy, and his free κ/λ light-chain ratio had become even more abnormal. At the current presentation, a technetium-99m pyrophosphate nuclear scintigram revealed a free κ/λ light-chain ratio of 1.52. This, combined with the patient's age and slow progression of primarily cardiac disease, supported the diagnosis of ATTR, and we prescribed tafamadis. This case suggests that technetium-99m pyrophosphate scintigraphy is valuable in definitively diagnosing ATTR cardiomyopathy and selecting patients who may benefit from disease-modifying therapy.

Meta-Analysis Comparing Venoarterial Extracorporeal Membrane Oxygenation With or Without Impella in Patients With Cardiogenic Shock.

Cardiogenic shock is associated with high short-term mortality. Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is increasingly used as a mechanical circulatory support strategy for patients with refractory cardiogenic shock. A drawback of this hemodynamic support strategy is increased left ventricular (LV) afterload, which is mitigated by concomitant use of Impella (extracorporeal membrane oxygenation with Impella [ECPELLA]). However, data regarding the benefits of this approach are limited. We conducted a systematic search of Medline, EMBASE, and Cochrane databases to identify studies including patients with cardiogenic shock reporting clinical outcomes with Impella plus VA-ECMO compared with VA-ECMO alone. Primary outcome was short-term all-cause mortality (in-hospital or 30-day mortality). Secondary outcomes included major bleeding, hemolysis, continuous renal replacement therapy, weaning from mechanical circulatory support, limb ischemia, and transition to destination therapy with LV assist device (LVAD) or cardiac transplant. Of 2,790 citations, 7 observational studies were included. Of 1,054 patients with cardiogenic shock, 391 were supported with ECPELLA (37%). Compared with patients on only VA-ECMO support, patients with ECPELLA had a lower risk of short-term mortality (risk ratio [RR] 0.89 [0.80 to 0.99], I2 = 0%, p = 0.04) and were significantly more likely to receive a heart transplant/LVAD (RR 2.03 [1.44 to 2.87], I2 = 0%, p <0.01). However, patients with ECPELLA had a higher risk of hemolysis (RR 2.03 [1.60 to 2.57], I2 = 0%, p <0.001), renal failure requiring continuous renal replacement therapy (RR 1.46 [1.23 to 174], I2 = 11%, p <0.0001), and limb ischemia (RR 1.67 [1.15 to 2.43], I2 = 0%, p = 0.01). In conclusion, among patients with cardiogenic shock requiring VA-ECMO support, concurrent LV unloading with Impella had a lower likelihood of short-term mortality and a higher likelihood of progression to durable LVAD or heart transplant. However, patients supported with ECPELLA had higher rates of hemolysis, limb ischemia, and renal failure requiring continuous renal replacement therapy. Future prospective randomized are needed to define the optimal treatment strategy in this high-risk cohort.

Benefits of Adding Glucagon-Like Peptide 1 Receptor Agonists to Sodium-Glucose Co-Transporter 2 Inhibitors in Diabetic Patients With Atherosclerotic Disease and Heart Failure.

Sodium-glucose co-transporter 2 inhibitors (SGLT2i) reduce the risk of cardiovascular events and heart failure hospitalization (HFH) in patients with heart failure with reduced ejection fraction (HFrEF), diabetes mellitus type 2 (DM2), and atherosclerotic cardiovascular disease (ASCVD). The role of glucagon-like peptide 1 agonists (GLP1a) in these patients is unclear. We designed this study to assess if the addition of GLP1a to SGLT2i therapy improves outcomes in patients with HFrEF, DM2, and ASCVD. This was a retrospective cohort study of patients with DM2, ASCVD, and HFrEF in the national Veterans Affairs database. Patients on SGLT2i were propensity matched to patients on both SGTL2i and GLP1a. The co-primary outcomes were HFH and the composite of all-cause death, myocardial infarction, and stroke. We assessed them through a Cox regression model including unbalanced baseline characteristics. From a cohort of 5,576 patients, 343 were propensity matched to each study arm. The addition of GLP1a was associated with a 67% reduction in the 1-year risk of a composite event compared with therapy with SGLT2i (confidence interval 0.138 to 0.714, p = 0.007). The risk of HFH was not significantly different between both arms (p = 0.199). Sensitivity analyses in the unmatched dataset confirmed these findings. In conclusion, the addition of GLP1a to SGLT2i may reduce the risk of adverse events in patients with HFrEF who have DM2 and ASCVD, but it does not affect the risk of HFH.

The Impact of Environmental Factors on the Mortality of Patients With Chronic Heart Failure.

Outcomes of acute heart failure hospitalizations are worse during the winter than the rest of the year. Seasonality data are more limited for outcomes in chronic heart failure and the effect of environmental variables is unknown. In this population-level study, we merged 20-year data for 555,324 patients with heart failure from the national Veterans Administration database with data on climate from the National Oceanic and Atmospheric Administration and air pollutants by the Environmental Protection Agency. The outcome was the all-cause mortality rate, stratified by geographical location and each month. The impact of environmental factors was assessed through Pearson's correlation and multiple regression with a family-wise α = 0.05. The monthly all-cause mortality was 13.9% higher in the winter than the summer, regardless of gender, age group, and heart failure etiology. Winter season, lower temperatures, and higher concentrations of nitrogen dioxide were associated with a higher mortality rate in multivariate analysis of the overall population. Different environmental factors were associated in regions with similar patterns of temperature and precipitation. The only environmental factor associated with the mortality rate of patients dwelling in large urban centers was the air quality index. In conclusion, the mortality in chronic heart failure exhibits a seasonal pattern, regardless of latitude or climate. In this group of patients, particularly those of male gender, a higher mortality was associated with environmental factors and incorporating these factors in treatment plans and recommendations could have a favorable cost-benefit ratio.

The Effect of Calcium Channel Blockers on Moderate or Severe Albuminuria in Diabetic, Hypertensive Patients.

OBJECTIVES: Inhibitors of the renin-angiotensin system are recommended for the management of albuminuria in patients with hypertension and diabetes mellitus, but there is little consensus about alternative therapies. Calcium channel blockers are recommended for the management of hypertension, but the data are controversial regarding their role in patients with albuminuria. This review was designed to assess the efficacy of calcium channel blockers compared with inhibitors of the renin-angiotensin system in decreasing albuminuria in diabetic, hypertensive patients with nephropathy. METHODS: We searched MEDLINE, Embase, CENTRAL, and ClinicalTrials.gov for records that compared calcium channel blockers to inhibitors of the renin-angiotensin system and reported pre- and postintervention albuminuria measurements. Two reviewers independently screened abstracts for randomized, controlled trials in adults. We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to select 29 trials from 855 records. We synthesized the data through a random-effects model. RESULTS: We analyzed data from 2113 trial participants with hypertension and diabetes mellitus who had the equivalent of ≥30 mg/day of urinary albumin excretion. Inhibitors of the renin-angiotensin system were more effective than calcium channel blockers in decreasing albuminuria (standardized difference in means -0.442; confidence interval, -0.660 to -0.225; P < .001). This finding was independent of the blood pressure response to treatment. There was no difference between the 2 drug classes regarding markers of renal function. CONCLUSIONS: Inhibitors of the renin-angiotensin system are superior to calcium channel blockers for the reduction of albuminuria in nephropathy due to hypertension and diabetes mellitus. The net clinical benefit, however, is small.

Anticoagulación sostenible en COVID-19: Revisión de predicción de gravedad y razonamiento clínico / Sustainable anticoagulation in COVID-19: Review of severity prediction and clinical reasoning

RESUMEN Objetivo Identificar el fenómeno procoagulante en pacientes SARS-CoV- 2 y proponer orientación terapéutica sostenible para países de bajos ingresos. Método Se realizó una revisión sistemática que identificó cinco estudios observacionales de un escrutinio a partir de 78 resultados. Se examinaron 712 pacientes y los resultados fueron agrupados según mortalidad y severidad. La comparación de los grupos se interpretó mediante estadística descriptiva. Resultado Los valores del dímero D se asociaron significativamente en todas las observaciones a mayor severidad y mortalidad. La protrombina se asoció, en algunas observaciones, a mayor mortalidad; en cuanto a severidad, los resultados fueron inconclusos. Conclusión El COVID-19 tiene importante actividad procoagulante y su tratamiento oportuno puede alterar el pronóstico. La evidencia explorada avala métodos sostenibles. Se necesita más evidencia para mejorar el manejo. Se recomienda un abordaje sistemático temprano de los pacientes con medidas terapéuticas sostenibles a la medida del sistema de salud.

ABSTRACT Objective To identify the procoagulant phenomenon in SARS-CoV-2 patients and propose sustainable therapeutic guidance for low-income countries. Methods A systematic review was conducted. It identified 5 observational studies from a scrutiny from 78 results. 712 patients were examined and the results were grouped according to mortality and severity. The comparison of the groups was interpreted using descriptive statistics. Results D-dimer values were significantly associated with greater severity and mortality. Prothrombin was associated in some observations with higher mortality, but in terms of severity it was inconclusive. Conclusion COVID-19 disease has significant procoagulant activity and its timely treatment can alter the prognosis. The explored evidence supports sustainable methods. More evidence is needed to improve management. An early systematic approach to patients with sustainable therapeutic measures tailored to the health system is recommended.

[Sustainable anticoagulation in COVID-19: Review of severity prediction and clinical reasoning]. / Anticoagulación sostenible en COVID-19: Revisión de predicción de gravedad y razonamiento clínico.

OBJECTIVE: To identify the procoagulant phenomenon in SARS-CoV-2 patients and propose sustainable therapeutic guidance for low-income countries. METHODS: A systematic review was conducted. It identified 5 observational studies from a scrutiny from 78 results. 712 patients were examined and the results were grouped according to mortality and severity. The comparison of the groups was interpreted using descriptive statistics. RESULTS: D-dimer values were significantly associated with greater severity and mortality. Prothrombin was associated in some observations with higher mortality, but in terms of severity it was inconclusive. CONCLUSION: COVID-19 disease has significant procoagulant activity and its timely treatment can alter the prognosis. The explored evidence supports sustainable methods. More evidence is needed to improve management. An early systematic approach to patients with sustainable therapeutic measures tailored to the health system is recommended.

OBJETIVO: Identificar el fenómeno procoagulante en pacientes SARS-CoV- 2 y proponer orientación terapéutica sostenible para países de bajos ingresos. MÉTODO: Se realizó una revisión sistemática que identificó cinco estudios observacionales de un escrutinio a partir de 78 resultados. Se examinaron 712 pacientes y los resultados fueron agrupados según mortalidad y severidad. La comparación de los grupos se interpretó mediante estadística descriptiva. RESULTADO: Los valores del dímero D se asociaron significativamente en todas las observaciones a mayor severidad y mortalidad. La protrombina se asoció, en algunas observaciones, a mayor mortalidad; en cuanto a severidad, los resultados fueron inconclusos. CONCLUSIÓN: El COVID-19 tiene importante actividad procoagulante y su tratamiento oportuno puede alterar el pronóstico. La evidencia explorada avala métodos sostenibles. Se necesita más evidencia para mejorar el manejo. Se recomienda un abordaje sistemático temprano de los pacientes con medidas terapéuticas sostenibles a la medida del sistema de salud.

Prognostic Utility of Troponin I and N Terminal-ProBNP among Patients with Heart Failure due to Non-Ischemic Cardiomyopathy and Important Correlations.

BACKGROUND: Heart Failure (HF) is accompanied by a high cost of care and gloomy prognosis despite recent advances in its management. Therefore, efforts to minimize HF rehospitalizations is a major focus of several studies. METHODS: We conducted a retrospective cohort study of 140 patients 18 years and above who had baseline clinical parameters, echocardiography, NT-ProBNP, troponin I and other laboratory parameters following a 3-year electronic medical record review. Patients with coronary artery disease, preserved ejection fraction, pulmonary embolism, cancer, and end-stage renal disease were excluded. RESULTS: Of the 140 patients admitted with HF with reduced Ejection Fraction (HFrEF) secondary to non-ischemic cardiomyopathy, 15 were re-hospitalized within 30 days of discharge while 42 were rehospitalized within 6 months after discharge for decompensated HF. Receiver operating characteristic (ROC) cutoff points were obtained for NT-ProBNP at 5178 pg/ml and serum troponin I at 0.045 ng/ml. After Cox regression analysis, patients with HFrEF who had higher hemoglobin levels had reduced odds of re-hospitalization (p = 0.007) within 30 days after discharge. NT-ProBNP and troponin I were independent predictors of re-hospitalization at 6 months after discharge (p = 0.047 and p = 0.02), respectively, after Cox regression analysis. CONCLUSION: Troponin I and NT-ProBNP at admission are the best predictors of re-hospitalization 6 months after discharge among patients with HFrEF. Hemoglobin is the only predictor of 30 -day rehospitalization among HFrEF patients in this study. High-risk patients may require aggressive therapy to improve outcomes.

Relationship between pulmonary hypertension and outcomes among patients with heart failure with reduced ejection fraction.

Objectives: To identify predictors of pulmonary hypertension (PHT) and the predictive value of PHT for rehospitalization among patients with heart failure with reduced ejection fraction (HFrEF). Methods: A retrospective study of 351 hospitalized patients with heart failure (HF). Patients 18 years and above with HFrEF secondary to non-ischemic cardiomyopathy were reviewed. Patients with coronary artery disease, preserved ejection fraction and other secondary causes of PHT apart from HF were excluded. PHT as a predictor of 30-day and six-month re-admission was assessed as well as important possible predictors of PHT. Cox regression analysis, multiple linear regression as well as other statistical tools were employed as deemed appropriate. Results: Thirty-seven (37) and 99 patients were re-hospitalized within 30 days and 6 months after discharge for decompensated HF, respectively. After Cox regression analysis, higher hemoglobin reduced the odds of rehospitalization for decompensated HF (p = 0.015) within 30 days after discharge while higher pulmonary artery systolic pressure (PASP) (p = 0.002) and blood urea nitrogen (BUN) (p = 0.041) increased the odds of rehospitalization within 6 months of discharge. The predictors of the PHT among patients with HFrEF after multiple linear regression were low BMI (p = 0.027), increasing age (p = 0.006) and increased left atrial diameter (LAD) on echocardiography (p = 0.0001). Conclusion: Patients with HFrEF have a high predisposition to developing PHT if at admission, they have low BMI, dilated left atrium or are older. Patients with one or more of these attributes may need more intensive therapy to reduce the risk of developing PHT and in turn reduce readmission rates.

Genetic Alleles Associated with SLE Susceptibility and Clinical Manifestations in Hispanic Patients from the Dominican Republic.

PURPOSE: Systemic lupus erythematosus (SLE) is a complex autoimmune disease with marked disparities in prevalence and disease severity among different ethnic groups. The purpose of this study is to characterize a Latin American cohort and identify genetic risk factors for developing SLE and its end-organ manifestations in this Latin Hispanic cohort. METHODS: A total of 201 SLE cases and 205 non-diseased controls were recruited in the Dominican Republic (DR). Cases were defined according to the 1997 revised American College of Rheumatology criteria for the classification of SLE. Genomic DNA was prepared from whole blood and applied to genotyping analyses for 42 single nucleotide polymorphisms (SNPs) that have been implicated in autoimmune diseases, including SLE, in other ethnic populations. Data were analyzed by Fisher's Exact Probability Test. RESULTS: In this cohort, SNP rs9271366 (tag SNP for HLA-DRB1*15:01) confers the highest risk for SLE among the 13 MHC gene alleles that display association with SLE (p = 8.748E-10; OR = 3.5). Among the 26 non-MHC gene alleles analyzed, SNP rs2476601 in PTPN22 gene confers the highest risk for SLE (p = 0.0001; OR = 5.6). ITGAM, TNFSF4, TNIP1, STAT4, CARD11, BLK, and TNXB gene alleles were confirmed as SLE-susceptible alleles in the DR cohort. However, IRF5 and TNFAIP3 gene alleles, established risk factors for SLE in populations of European and Asian ancestry, are not significantly associated with SLE in this cohort. We also defined a novel HLA-DRA haplotype that confers an increased risk for lupus nephritis (LN) and alleles in HLA-DRA2 and TNFSF4 genes as genetic risk factors for developing neuropsychiatric (NP) SLE. CONCLUSION: Our data suggest that the Latin American population shares some common genetic risk factors for SLE as other populations, but also has distinct risk gene alleles that contribute to SLE susceptibility and development of LN and NPSLE. This is the first study focusing on genetic risk factors for SLE in the DR, a Latin American population that has never been characterized before.

The Effect of Vegan Diets on Blood Pressure in Adults: A Meta-Analysis of Randomized Controlled Trials.

BACKGROUND: Vegan diets are increasing in popularity and have beneficial effects on glycemia and blood lipids, but the evidence is inconclusive regarding their effect on blood pressure. The purpose of this study was to review the effect of vegan diets on blood pressure in adults. METHODS: We searched MEDLINE, EMBASE, CENTRAL, and ClinicalTrials.gov for records that compared a vegan diet with any less restrictive diet and reported pre- and postintervention systolic and diastolic blood pressures. Two reviewers independently screened abstracts for randomized, controlled clinical trials in individuals ≥18 years of age and older. We used the PRISMA guidelines to select 11 clinical trials from 1673 records. Data synthesis was performed through a random-effects model. RESULTS: The pooled data included 983 participants. Compared with less restrictive diets, a vegan diet did not result in a significant change in systolic (-1.33 mm Hg; 95% confidence interval [CI], -3.50-0.84; P = .230) or diastolic (-1.21 mm Hg; 95% CI, -3.06-0.65; P = .203) blood pressure. A prespecified subgroup analysis of studies with baseline systolic blood pressure ≥130 mm Hg revealed that a vegan diet resulted in a mean decrease in the systolic (-4.10 mm Hg; 95% CI, -8.14 to -0.06; P = .047) and diastolic (-4.01 mm Hg; 95% CI, -5.97 to -2.05; P = 0.000) blood pressures. CONCLUSION: The changes in blood pressure induced by a vegan diet without caloric restrictions are comparable with those induced by dietary approaches recommended by medical societies and portion-controlled diets.

Low Skeletal Muscle Mass Independently Predicts Mortality in Patients with Chronic Heart Failure after an Acute Hospitalization.

BACKGROUND: Heart failure (HF) is a syndrome associated with exercise intolerance, and its symptoms are more common in patients with low skeletal muscle mass (SMM). Estimation of muscle mass can be cumbersome and unreliable, particularly in patients with varying body weight. The psoas muscle area (PMA) can be used as a surrogate of sarcopenia and has been associated with poor outcomes in other populations. OBJECTIVES: The aim of this study was to assess if sarcopenia is associated with the survival of patients with HF after an acute hospitalization. METHOD: We retrospectively studied a cohort of 160 patients with HF who had abdominopelvic computed tomography during an acute hospitalization. We obtained standardized measurements of their PMA and defined sarcopenia as the lowest gender-based tertile of the said area. The patients were followed until death or discontinuation of care. We used Kaplan-Meier estimates and Cox regression analysis to assess the relationship between sarcopenia and all-cause mortality. RESULTS: We found that the 52 patients with sarcopenia had 4.5 times the risk of all-cause mortality at 1 year compared to the rest of the cohort (CI 1.784-11.765; p = 0.0016) after adjusting for significant covariates. Stratification by age and sex revealed that this association could be limited to males and patients < 75 years old. CONCLUSION: The PMA, used as a surrogate of low SMM, is independently associated with an increased risk of late mortality after an acute hospitalization in patients with HF.

Clinical outcomes of Β-blocker therapy in cocaine-associated heart failure.

BACKGROUND: Cocaine is associated with deleterious effects in the heart, including HFrEF. Although ß-blockers are recommended for this condition in other populations, their use is discouraged in cocaine users due to the possibility of exacerbating cocaine-related cardiovascular complications. This study was designed to determine if patients with heart failure and a reduced ejection fraction (HFrEF) who continue to use cocaine have better outcomes when they receive ß-blocker therapy than when they do not. METHODS: We performed a retrospective analysis of 72 ß-blocker-naïve patients with HFrEF and active cocaine use. Patients who were prescribed ß-blockers as part of their therapy were compared to those who were not, and clinical and structural outcomes were compared after 12 months of treatment. RESULTS: When patients with HFrEF and active cocaine use received ß-blocker therapy, they were more likely to have an improvement in their New York Heart Association functional class (p = 0.0106) and left ventricular ejection fraction (p = 0.0031) than when they did not receive ß-antagonists. In addition, the risk of cocaine-related cardiovascular events (p = 0.0086) and of heart failure hospitalizations (p = 0.0383) was significantly lower in patients who received ß-blockade than those who did not. CONCLUSIONS: ß-Blocker therapy is associated with improvement in the exercise tolerance and the left ventricular ejection fraction in patients with HFrEF and active cocaine use. They are also associated with a lower incidence of cocaine-related cardiovascular events and HFrEF-related readmissions.

Brugada Phenocopy Induced by Recreational Drug Use.

Recreational drugs are commonly abused in all age groups. Intoxication with these substances can induce silent but significant electrocardiographic signs which may lead to sudden death. In this case study, we present a 49-year-old male with no medical comorbidities who came to the emergency department requesting opioid detoxification. Toxicology screen was positive for cocaine, heroin, and cannabis. Initial electrocardiogram (EKG) showed features of a Brugada pattern in the right precordial leads, which resolved within one day into admission. This presentation is consistent with the recently recognized clinical entity known as Brugada phenocopy.

Improvement in clinical outcomes of patients with heart failure and active cocaine use after ß-blocker therapy.

BACKGROUND: Cocaine use has a high prevalence in the United States and can be associated with significant cardiovascular disease, even in asymptomatic users. ß-Adrenergic receptor hyperactivation is the underlying pathophysiologic pathway of cocaine cardiotoxicity. ß-Blocker therapy is controversial in patients with active cocaine use. HYPOTHESIS: ß-Blocker therapy is associated with clinical improvement in patients with heart failure despite active cocaine use. METHODS: In a single-center, retrospective chart analysis, patients with newly diagnosed heart failure and active cocaine use who had been started on ß-blocker therapy were reviewed. The New York Heart Association (NYHA) functional class and the left ventricular ejection fraction (LVEF) were recorded at baseline and after 12 monthsnthsnths of ß-blocker use. Patients were excluded if they had been on prior ß-blocker therapy, had other reasons for volume overload, had chronic kidney disease stages G4 or G5, or had a life expectancy <12 months. RESULTS: Thirty-eight patients were identified; most were African American males. A statistically significant improvement was found in both NYHA functional class (P < 0.0001) and LVEF (P < 0.0001) after 12 months of ß-blocker therapy. No major adverse cardiovascular events occurred in this population. CONCLUSIONS: ß-Blocker use in cocaine users with heart failure with a reduced ejection fraction is associated with a lower NYHA functional class and a higher LVEF at 12-month follow-up. No major adverse cardiovascular events were observed.

Atrial Fibrillation in Patients with Heart Failure: Current State and Future Directions.

Heart failure affects nearly 26 million people worldwide. Patients with heart failure are frequently affected with atrial fibrillation, and the interrelation between these pathologies is complex. Atrial fibrillation shares the same risk factors as heart failure. Moreover, it is associated with a higher-risk baseline clinical status and higher mortality rates in patients with heart failure. The mechanisms by which atrial fibrillation occurs in a failing heart are incompletely understood, but animal studies suggest they differ from those that occur in a healthy heart. Data suggest that heart failure-induced atrial fibrosis and atrial ionic remodeling are the underlying abnormalities that facilitate atrial fibrillation. Therapeutic considerations for atrial fibrillation in patients with heart failure include risk factor modification and guideline-directed medical therapy, anticoagulation, rate control, and rhythm control. As recommended for atrial fibrillation in the non-failing heart, anticoagulation in patients with heart failure should be guided by a careful estimation of the risk of embolic events versus the risk of hemorrhagic episodes. The decision whether to target a rate-control or rhythm-control strategy is an evolving aspect of management. Currently, both approaches are good medical practice, but recent data suggest that rhythm control, particularly when achieved through catheter ablation, is associated with improved outcomes. A promising field of research is the application of neurohormonal modulation to prevent the creation of the "structural substrate" for atrial fibrillation in the failing heart.