Diagnosis and Management of Heart Failure in Long-Term Dialysis Patients.

PURPOSE OF REVIEW: Development of congestive heart failure as a manifestation of various cardiovascular ailments is not only an adverse prognostic factor for patients on long-term dialysis but its presence at the initiation of hemodialysis is another independent indicator of higher mortality. RECENT FINDINGS: The literature reviewed included the most recent studies that assessed the prevalence, incidence, and risk factors associated with dialysis in the setting of congestive heart failure. Improving outcomes for patients with heart failure in long-term dialysis continues to constitute a challenge due to the complexity of these illnesses and the lack of clear consensus to guide diagnosis and management.

Hospital Management of Acute Decompensated Heart Failure.

Heart failure (HF) is one of the leading causes of hospitalizations for elderly adults in the United States. One in 5 Americans will be >65 years of age by 2050. Because of the high prevalence of HF in this group, the number of Americans requiring hospitalization for this disorder is expected to rise significantly. We reviewed the most recent and ongoing studies and recommendations for the management of patients hospitalized due to decompensated HF. The Acute Decompensated Heart Failure National Registry, together with the 2013 American College of Cardiology Foundation and American Heart Association heart failure guidelines, earlier retrospective and prospective studies including the Diuretic Optimization Strategies Evaluation (DOSE), the Trial of Intensified vs Standard Medical Therapy in the Elderly Patients With Congestive Heart Failure (TIME-CHF), the Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure (OPTIMIZE-HF), the Rapid Emergency Department Heart Failure Outpatient Trial (REDHOT) and the Comparison of Medical, Pacing and Defibrillation Therapies in Heart Failure (COMPANION) trial were reviewed for current practices pertaining to these patients. Gaps in our knowledge of optimal use of patient-specific information (biomarkers and comorbid conditions) still exist.

Geriatrics: (women's health series).

As women age, they face challenging health issues. Their average life expectancy is longer than their male counterparts, yet they often have multiple chronic, ongoing health problems that complicate their care, accentuate their infirmity, and reduce their quality of life. Often, they fail to receive the same quality or amount of healthcare service, sometimes because of a lack of data specific to their demographics, at other times for myriad unclear reasons. What data are available suggest that they will usually glean the same benefits as their male and younger female counterparts, often with little increased risk of adverse effects from available medical diagnostic and therapeutic options. Cardiovascular disease, malignancies, musculoskeletal disorders (particularly osteoporosis), and cognitive and psychiatric illness are the most frequent, and often most devastating, health issues in this growing segment of the population. An understanding of the differences in disease frequencies, presentations, and response to treatments is necessary to provide older adult women with optimal health care.

Significance of elevated cardiac troponin I in patients with diabetic ketoacidosis.

BACKGROUND: Cardiac troponin I displays significant prognostic value in acute coronary syndromes and in other non-coronary conditions and systemic illnesses. Elevated levels of this biomarker in the setting of diabetic ketoacidosis may also provide useful prognostic information regarding outcome. METHODS: A systematic review of the English language medical literature was performed using PubMed. Articles reporting original data on major clinical outcomes on cohorts of patients were included. RESULTS: Three reports examining the relationship between cardiac troponin I and clinical outcomes in patients with diabetic ketoacidosis qualified for review. A spectrum of electrolyte and cardiac abnormalities were observed in the studied populations which were more frequent in those with troponin elevations. Short- and long-term outcomes appeared worse for patients with elevated troponin levels, but small study populations and other experimental issues including concurrent diseases which could have confounded the apparent relationship between troponin concentrations and outcome reduced the confidence of the findings. CONCLUSIONS: The available literature suggests an association between elevated cardiac-specific troponin I serum concentrations and clinical outcomes among diabetic patients with ketoacidosis, but data are insufficient to draw conclusions at this time. Large prospective observational studies which exclude or control for other conditions which could contribute to troponin release will be needed before the predictive value of this biomarker in ketoacidosis can be reliably defined.

Prognostic value of cardiac-specific troponins in intracranial hemorrhage.

BACKGROUND: Cardiac-specific troponin (Tn) serum concentrations have proved to be important diagnostic and prognostic markers for acute myocardial infarction. Elevated levels in the setting of noncardiac diseases such as intracerebral hemorrhage also may provide useful prognostic information regarding outcome. METHODS: A systematic review of the English-language medical literature was performed using PubMed. Articles reporting original data were included. RESULTS: Ten reports qualified for review. A spectrum of cardiac abnormalities was observed in studied patients, sometimes more frequently in those with Tn elevations, whereas some had no such abnormalities, even if Tn was detected. Although some studies suggested a worse outcome in patients with elevated Tn levels, the findings were inconsistent. CONCLUSIONS: At this time, although the literature suggests an association between cardiac-specific Tn elevations and clinical events in patients with intracranial hemorrhage, data are insufficient to conclude that there is a consistent predictive value or to recommend routine Tn monitoring for prognosis.

Non-enteral therapy for hypertension in the inpatient setting.

Chronic hypertension requiring treatment with regularly administered oral medications is the most common cardiovascular disease among adults. When patients with hypertension suffer an illness which requires hospitalization and precludes normal oral drug intake, blood pressure may rise sufficiently to require alternative treatments. Consequences of the acute illnesses themselves and their treatments may also elevate blood pressure and further complicate antihypertensive management. The optimal medical regimen to control blood pressure under these circumstances depends upon a number of variables, including co-morbid conditions, concurrently administered drugs, and the overall clinical stability of the patient. This paper reviews issues related to hypertension in the hospitalized patient unable to take oral medications and summarizes antihypertensive treatment options based on clinical and pharmacological considerations.

Managing chronic heart failure patient in chronic kidney disease.

Management of systolic heart failure can be particularly challenging in patients with chronic kidney disease, especially those who are not yet receiving dialysis. Few clinical trials have been performed in this particular population, so management is directed by evidence from studies of patients with limited or no renal impairment. Their heightened risk for many treatment complications mandates additional considerations regarding drug selection, dosing, and monitoring. Subspecialty consultation is driven by patient instability or disease progression, intolerance of standard treatment, or need for device placement.

Dilated cardiomyopathy and role of antithrombotic therapy.

BACKGROUND: There is no consensus as to whether anticoagulation has a favorable risk:benefit in reducing thromboembolic events in patients with heart failure (HF) secondary to dilated cardiomyopathy who do not suffer from atrial fibrillation or primary valvular disease. METHODS AND RESULTS: The literature reviewed on this topic included most recent and ongoing studies that assessed the use of anticoagulation for this population. Several large retrospective studies showed an increased risk of thromboembolic events among patients with depressed left ventricular function. The relative risk of stroke in individuals with HF from all causes was found to be 4.1 for men and 2.8 for women, but confounding comorbidities (such as atrial fibrillation and coronary artery disease) were commonly present. Currently, there are no randomized prospective trials to guide the use of antithrombotics for these patients, and the risk of bleeding secondary to anticoagulation has limited the use of oral anticoagulants for prevention of thrombosis. Among patients with HF, increasing age directly correlates with both major bleeding and thromboembolic events, with a 46% relative risk of bleeding for each 10-year increase in age older than 40 years. CONCLUSIONS: To date, there is no agreement on appropriate antithrombotic treatment (if any) for primary thromboembolism prophylaxis in patients with dilated cardiomyopathy with sinus rhythm. In recent years, several promising prospective trials were terminated prematurely due to inadequate enrollment. The Warfarin Aspirin-Reduced Cardiac Ejection Fraction trial may provide evidence regarding the use of anticoagulation for patients with decreased myocardial function.

HLA sensitization in ventricular assist device recipients: does type of device make a difference?

BACKGROUND: We sought to (1) characterize the temporal pattern of T-cell panel reactive antibody during ventricular assist device support, (2) identify predictors of higher T-cell panel reactive antibody during ventricular assist device support, and (3) determine whether device type remained a predictor after accounting for nonrandom device selection. METHODS: Between December 1991 and August 2000, 239 patients received implantable ventricular assist devices, of whom 231 had T-cell panel reactive antibody measured. Panel reactive antibody was measured before implantation of the assist device, approximately 2 weeks after device implantation, irregularly thereafter depending on clinical events and length of support, and at transplantation. Longitudinal mixed modeling was used to characterize the temporal pattern of sensitization and its predictors during ventricular assist device support. To account for nonrandom factors in device selection when comparing HeartMate (Thermo Cardiosystems, Inc, Woburn, Mass) and Novacor (Baxter Healthcare Corp, Novacor Div, Oakland, Calif) devices, we propensity-matched patients according to baseline characteristics. RESULTS: T-cell panel reactive antibody increased rapidly after implantation of the ventricular assist device and then immediately began to decrease. Predictors of higher T-cell panel reactive antibody during support with the assist device were a shorter interval from device implantation to T-cell panel reactive antibody measurement (P <.0001), female sex (P =.0004), younger age (P =.01), higher T-cell panel reactive antibody before device implantation (P =.03), more perioperative red blood cell transfusions (P =.006), and an earlier date of device implantation (P =.001). In matched patients, device type was not a predictor of higher T-cell panel reactive antibody during ventricular assist device support (P =.8). CONCLUSIONS: HLA sensitization during ventricular assist device support is not constant but increases rapidly at implantation and then decreases. This temporal pattern of sensitization is influenced by patient factors and not by the type of device.