Outcome differences in acute vs. acute on chronic heart failure and cardiogenic shock.

AIMS: Despite advances in coronary reperfusion and percutaneous mechanical circulatory support, mortality among patients presenting with cardiogenic shock (CS) remains unacceptably high. Clinical trials and risk stratification tools have largely focused on acute CS, particularly secondary to acute coronary syndrome. Considerably less is understood about CS in the setting of acute decompensation in patients with chronic heart failure (HF). We sought to compare outcomes between patients with acute CS and patients with acute on chronic decompensated HF presenting with laboratory and haemodynamic features consistent with CS. METHODS AND RESULTS: Sequential patients admitted with CS at a single quaternary centre between January 2014 and August 2017 were identified. Acute on chronic CS was defined by having a prior diagnosis of HF. Initial haemodynamic and laboratory data were collected for analysis. The primary outcome was in-hospital mortality. Secondary outcomes were use of temporary mechanical circulatory support, durable ventricular assist device implantation, total artificial heart implantation, or heart transplantation. Comparison of continuous variables was performed using Student's t-test. For categorical variables, the χ2 statistic was used. A total of 235 patients were identified: 51 patients (32.8%) had acute CS, and 184 patients (64.3%) had acute decompensation of chronic HF with no differences in age (52 ± 22 vs. 55 ± 14 years, P = 0.28) or gender (26% vs. 23%, P = 0.75) between the two groups. Patients with acute CS were more likely to suffer in-hospital death (31.4% vs. 9.8%, P < 0.01) despite higher usage of temporary mechanical circulatory support (52% vs. 25%, P < 0.01) compared with patients presenting with acute on chronic HF. The only clinically significant haemodynamic differences at admission were a higher heart rate (101 ± 29 vs. 82 ± 17 b.p.m., P < 0.01) and wider pulse pressure (34 ± 19 vs. 29 ± 10 mmHg, P < 0.01) in the acute CS group. There were no significant differences in degree of shock based on commonly used CS parameters including mean arterial pressure (72 ± 12 vs. 74 ± 10 mmHg, P = 0.23), cardiac output (3.9 ± 1.2 vs. 3.8 ± 1.2 L/min, P = 0.70), or cardiac power index (0.32 ± 0.09 vs. 0.30 ± 0.09 W/m2 , P = 0.24) between the two groups. CONCLUSIONS: Current definitions and risk stratification models for CS based on clinical trials performed in the setting of acute coronary syndrome may not accurately reflect CS in patients with acute on chronic HF. Further investigation into CS in patients with acute on chronic HF is warranted.

Complete neurologic recovery in an out-of-hospital cardiac arrest facilitated by initiation of therapeutic hypothermia in a young athlete with an anomalous right coronary artery.

Therapeutic hypothermia is an accepted modality for improving neurologic outcome in patients who have sustained cardiac arrest with return of spontaneous circulation. Despite postresuscitative neuroprotection, it is uncommon to have patients who have undergone prolonged cardiopulmonary resuscitation to recover full neurologic function. An unusual case of sudden cardiac arrest in a young athlete with an anomolous right coronary artery is presented.

Cost-effectiveness of LTBI treatment for TB contacts in British Columbia.

BACKGROUND: Contacts of patients with active tuberculosis ("TB contacts") with a tuberculin skin test (TST) size > or = 5 mm are currently recommended treatment for latent TB infection (LTBI). Knowing the cost-effectiveness of LTBI therapy for specific TB contact subpopulations may improve the use of limited resources by reducing the treatment of persons at low TB risk. OBJECTIVE: To evaluate the cost-effectiveness of LTBI therapy for different TB contact populations defined by important risk factors, and to propose an optimal policy based on different recommendation for each subgroup of contacts. METHODS: A 6-year Markov decision analytic model simulating the quality-adjusted life years (QALYs), number of active TB cases prevented, and costs for hypothetical cohorts of Canadian TB contacts defined by TST size, age group (< 10 y/o or above), ethnicity, closeness of contact, and Bacillus Calmette-Guérin (BCG) vaccination status. RESULTS: For the majority of subgroups, the current policy of preventive therapy in those with positive TST was the most cost-effective. Nevertheless, our analysis determined that LTBI treatment is not cost-effective in nonhousehold Canadian-born (nonaboriginal) or foreign-born contacts age > or = 10 y/o. On the other hand, empirical treatment without screening of all non-BCG-vaccinated household contacts age < 10 y/o appeared cost-effective. Such an optimal approach would result in an incremental net monetary benefit of $25 for each contact investigated for a willingness-to-pay of $50,000/QALY. Results were robust to several alternative assumptions considered in sensitivity analyses. CONCLUSIONS: The current practice of LTBI treatment for TB contacts with a TST size > or = 5 mm is cost-effective. A customized approach based on excluding low risk groups from screening and providing treatment to high risk contacts without screening could improve the performance of the program.

Cost-effectiveness of continuous positive airway pressure therapy for moderate to severe obstructive sleep apnea/hypopnea.

BACKGROUND: Obstructive sleep apnea/hypopnea (OSAH) is a common disorder characterized by recurrent collapse of the upper airway during sleep, and is associated with an increased risk of motor vehicle crashes (MVCs). Common first-line therapy for OSAH is continuous positive airway pressure (CPAP). We assessed the cost-effectiveness of CPAP therapy vs none for the treatment of OSAH. METHODS: We used a 5-year Markov model that considers the costs and quality-of-life improvements of CPAP therapy, accounting for the gains from reduced MVC rates. Utility values were obtained from published studies. The MVC rates under the CPAP and no-CPAP scenarios were calculated from National Highway Traffic Safety Administration data and a systematic review of published studies. Costs of MVCs, equipment, and physicians were obtained from US Medicare and the National Highway Traffic Safety Administration. The target population included male and female patients aged 25 to 54 years and newly diagnosed as having moderate to severe OSAH. We examined the findings from the perspectives of a third-party payer and society. RESULTS: From a third-party payer or a societal perspective, CPAP therapy was more effective but more costly than no CPAP, with incremental cost-effectiveness ratios of $3354 or $314 per quality-adjusted life-year gained, respectively. The incremental cost-effectiveness ratio estimate was most dependent on viewpoint (varying more than 10-fold between societal and third-party payer perspectives) and choice of utility measurement method (varying more than 5-fold between the use of standard gamble and EuroQol 5D utility assessment values). CONCLUSION: When quality of life, costs of therapy, and MVC outcomes are considered, CPAP therapy for patients with OSAH is economically attractive.