Serial evaluation of loop diuretic efficiency following left ventricular assist device implantation.

More than 50% of heart failure (HF) patients require diuretic therapy after left ventricular assist device (LVAD). Although few data related to diuretic response (DR) exist in stage D patients, tubular sodium reabsorption may be clinically prognostic independent of estimated glomerular filtration rate (eGFR) and proteinuria within this cohort. We aimed to characterize DR serially before and after LVAD implantation in a stage D population. We conducted a prospective, observational cohort study of HF patients receiving diuretics with plans to undergo LVAD implantation. We measured urine sodium (UNa) and creatinine (UCr) at three points after diuretic therapy: pre-LVAD, post-LVAD prior to discharge, and as an outpatient. Prior to LVAD, patients (N = 19) had an average eGFR of 54.0 ± 18.0 mL/min/1.73 m2, spot UNa of 74.8 ± 28.0 mmol/L, and fractional excretion of sodium (FENa) of 3.1 ± 2.7%. Pre-LVAD, eGFR did not correlate with spot UNa nor FENa (p > 0.05 for both). LVAD implantation did not improve DR post-LVAD (mean change FENa per 40 mg IV furosemide 0.5 ± 1.0%; p = 0.84), and 90% of patients required loop diuretics at 90 days post-surgery. Improved hemodynamics following LVAD may not improve DR or tubular function; larger studies are needed to confirm our results and assess the utility of DR to predict post-LVAD outcomes.

Use of Tissue Plasminogen Activator Alteplase Purge Solution in an Impella 5.5 Heart Pump.

Standardized Impella purge solutions have traditionally consisted of 5-40% dextrose with or without unfractionated heparin as a means of anticoagulation. Such a solution serves to create a pressure barrier preventing entry of blood into the pump's motor housing with heparin providing adequate purge pathway patency in the event of this occurring. We present a case of tissue plasminogen activator (tPA, Activase) utilization in lieu of the recommended purge solution due to concern for thrombus formation of the purge pathway in a 51-year-old male with cardiogenic shock status-post Impella 5.5 heart pump placement for hemodynamic support while awaiting heart transplantation. The purge solution was successfully administered for 48 hours without complication and a reduction in average purge pressure with increase in purge flow rate was observed.

Impact of Pharmacist Intervention to Increase Compliance With Guideline-Directed Statin Therapy During an Acute Coronary Syndrome Hospitalization.

BACKGROUND: Despite evidence on poor adherence to guideline-directed statin therapy (GDST) following an acute coronary syndrome (ACS), little information has been published on pharmacist-led statin pilot programs for secondary prevention. OBJECTIVE: We sought to evaluate the impact of a pharmacist intervention (PI) on GDST during an ACS hospitalization. METHODS: A historical control (HC) group consisting of 125 ACS hospitalizations was retrospectively identified, with prospective data of 113 patients captured over 6 months in the PI group. The primary outcome of GDST was defined according to 2013 clinical guidelines and evaluated in all 238 qualifying patients. Secondary outcomes included number of interventions and use of logistic regression to investigate the relationship of ACS subtype with statin dose. RESULTS: On admission, GDST was ordered in 62.5% of the HC and 75.9% of the PI group. At discharge, the PI group had a higher rate of GDST relative to HC among all patients (86.7 % vs 77.4%, P = 0.06), and after exclusion of contraindications (84.8% vs 74.5%; P = 0.1), 10 patients required PI, accounting for an increase in GDST of 5.3%. Statin dose selection did not differ by ACS subtype (odds ratio = 0.79; 95% CI = 0.0.29-2.17; P = 0.18). CONCLUSION: PI did not significantly increase GDST. Increased compliance rates measured were primarily driven by higher baseline adherence and guideline incorporation over time.