Hypertrophic cardiomyopathy in pregnancy: Nationwide analysis of patients characteristics and outcomes.

INTRODUCTION: Hypertrophic cardiomyopathy (HCM) poses unique challenges in the management of pregnant patients due to the complex interplay of physiological changes of pregnancy. Despite its relatively low prevalence among pregnant women, HCM can significantly impact maternal and fetal outcomes. This study aims to enhance understanding of pregnant patients with HCM and the associated outcomes through a nationwide analysis of patient characteristics and outcomes. METHODS: A retrospective analysis was conducted using data obtained from the Agency for Healthcare Research in Quality (AHRQ) Nationwide Inpatient Sample (NIS) database from January 2016 to December 2020. 3,599,855 pregnant patients without HCM and 187 pregnant patients with HCM were identified using International Classification of Disease (ICD) codes, and baseline characteristics, medical comorbidities, and outcomes were compared between the two groups. RESULTS: Significant differences were observed in baseline characteristics, including age distribution, racial composition, and prevalence of systemic organ disease, between pregnant women with and without HCM. Women with HCM had higher odds of experiencing maternal complications, such as acute heart failure and peripartum cardiomyopathy, as well as higher rates of fetal distress and obstetric interventions, including preterm delivery and caesarean section. CONCLUSION: Comprehensive cardiovascular assessment and risk stratification are essential in pregnant women with HCM to optimize maternal and fetal outcomes. Moreover, disparities in baseline characteristics and outcomes among black pregnant women with HCM highlight the need for a multifactorial approach to addressing pregnancy-related complications.

Bariatric Weight Loss Surgery Improves Systolic Function in Obese Patients With Heart Failure.

Obesity has become a worldwide public health issue. Many obese patients concomitantly suffer with heart failure with reduced ejection fraction. There have been reports of improvement in left ventricular systolic function following significant weight loss after bariatric surgery. We sought to investigate this phenomenon within our institution. This was a retrospective single-center analysis of patients conducted between 2010 and 2019. The study included patients with morbid obesity (body mass index >35 kg/m2 and an obesity-related comorbid condition, or a body mass index >40 kg/m2) and left ventricular systolic dysfunction. Analysis was performed based on systolic function recovery after bariatric surgery and advanced heart failure therapy. Of the 190 patients identified, 57 patients had a left ventricular ejection fraction of <40%. Twenty-two patients underwent bariatric surgery, of which at least 54.5% had systolic function recovery. Patients who had systolic function recovery after bariatric surgery were significantly older (51.58 years ± 10.48 vs 32.3 years ± 5.03, P = 0.001). Older age and female sex were predictors of systolic function recovery. In patients with obesity and heart failure with reduced ejection fraction, weight loss following bariatric surgery was shown to be correlated with significant improvement in left ventricular systolic function.

Predicting the Severity and Outcome of Persistent Pulmonary Hypertension of the Newborn Using New Echocardiography Parameters.

To examine echocardiographic parameters correlation with clinical severity indices, Alveolar- arterial gradient (A-a gradient), oxygenation index and clinical outcomes in newborns with persistent pulmonary hypertension of the newborn (PPHN). Retrospective cohort study of 67 subjects, >35 weeks' gestation with the diagnosis of PPHN admitted to the University of Kentucky neonatal intensive care unit (NICU) between September 2014 and December 2016. High left ventricular end-systolic eccentricity index (EIs) correlates with the overall clinical severity of PPHN as it is associated with higher A-a gradient and oxygenation index (P = 0.0003 and P < 0.0001, respectively). Elevated EIs was also predictive for the use of inhaled nitric oxide and extracorporeal membrane oxygenation (P = 0.0004 and P < 0.0001, respectively). EIs value of >1.38 provides cutoff value as an objective marker for the need for extracorporeal membrane oxygenation. EIs can be used to assess clinical severity and outcomes and should be reported routinely. Further studies are warranted to confirm these results.

Ortner's syndrome: A rare case of hoarseness secondary to chronic aortic dissection.

Ortner's syndrome, also known as cardiovocal syndrome, is a rare presentation of aortic dissection. Symptoms occur as a result of recurrent laryngeal nerve compression. Our report describes a case of a patient who complained of hoarseness for a few months and was eventually diagnosed with chronic aortic dissection.

Impact of Digoxin Use on Guideline-Directed Medical Therapy in Patients With Heart Failure With Reduced Ejection Fraction.

Background: Digoxin was one of the first agents used in the management of heart failure with reduced ejection fraction (HFrEF). Concerns over its safety, efficacy, and the introduction of guideline-directed medical therapy (GDMT) have relegated it to a secondary role. The efficacy of digoxin is still under debate, and its use in patients on GDMT remains unclear. We aim to evaluate whether patients with HFrEF on digoxin can tolerate higher doses of a ß-blocker (BB), angiotensin-converting enzyme inhibitors (ACEIs), angiotensin receptor blocker (ARB), mineralocorticoid receptor antagonists (MRAs), and angiotensin receptor-neprilysin inhibitor (ARNI). Methods: A retrospective chart review was performed on 233 patients with HFrEF managed at a tertiary care center in Cleveland, Ohio. A bivariate analysis was performed to compare patients on digoxin with patients not on digoxin in terms of ability to progress the dosing of BB, ACEI, MRA, ARB, or ARNI. Results: Thirty-four (14.6%) of our 233 patients were receiving digoxin at baseline visit. The digoxin group was more likely to have lower initial and last systolic blood pressure, initial diastolic blood pressure, and left ventricular ejection fraction. Mean follow-up duration and baseline sodium level were higher in the digoxin group. There was no significant difference between the two groups in terms of patients receiving higher doses of BB (P = 0.235), ACEI/ARB (P = 0.903), MRA (P = 0.331), or ARNI (P = 0.717). Conclusions: There was no significant difference between the doses of BB, ACEI, ARB, MRA, or ARNI among HFrEF patients on digoxin compared to those that were not. Randomized control trials with a larger sample are needed to establish our findings of digoxin not significantly affecting the ability to up titrate GDMT in HFrEF patients.

Outcomes of acute pulmonary embolism in hospitalized patients with cancer.

BACKGROUND: Cancer-associated pulmonary embolism (PE) places a significant burden on patients and health care systems. METHODS: A retrospective cross-sectional analysis of the National Inpatient Sample (NIS) database was performed in patients with acute PE from 2002 to 2014. Among patients hospitalized with PE, we investigated the differences in clinical outcomes and healthcare utilization in patients with and without cancer. A multivariate logistic regression model was applied to calculate adjusted odds ratios (OR) to estimate the impact of cancer on clinical outcomes. Wilcoxon rank sum tests were used to determine the differences in healthcare utilization between the two cohorts. RESULTS: Among 3,313,044 patients who were discharged with a diagnosis of acute PE, 84.2% did not have cancer, while 15.8% had cancer as a comorbidity (56% metastatic cancer, 35% solid tumor without metastasis, and 9% lymphoma). Patients with cancer had a higher mean age but lower rates of common comorbidities except for coagulation deficiency than patients without a cancer diagnosis. In patients with cancer, the rate of IVC filter placement was higher (21.7% vs. 13.11%, OR 1.76 (95% CI 1.73-1.79); p < 0.0001) and thrombolytic use lower (1.34% vs. 2.15%, OR 0.68 (95% CI 0.64-0.72); p < 0.0001). Patients with cancer hospitalized for PE had a higher all-cause in-hospital mortality (11.8% vs. 6.6%, OR 1.79 (95% CI 1.75-1.83); p < 0.0001), longer length of stay (6 vs. 5 days; p < 0.0001), higher total charge per hospitalization ($30,885 vs. $27,273; p < 0.0001), and higher rates of home health services upon discharge (35.8% vs. 23.2%; p < 0.0001) compared with those without cancer. CONCLUSION: Concurrent cancer diagnosis in patients hospitalized for acute PE was associated with a 90% increase in all-cause mortality, longer length of stay, higher total charge per hospitalization, and higher rates of home health services upon discharge. The majority (56%) of patients with cancer had metastatic disease. Furthermore, there were identifiable differences in the intervention for acute PE between the two groups.

LVAD Vasculitis Case Series: Suggestion of a New Fatal LVAD-Related Phenomenon.

Left ventricular assist devices (LVADs) are surgically implanted mechanical devices indicated for patients with advanced heart failure and are known to come with several complications. Here we present a case series, and review 1 documented report, of LVAD vasculitis, a presumed new LVAD immune/humoral related phenomenon. (Level of Difficulty: Advanced.).

Clinical outcomes of older adults listed for heart transplantation in the United States.

OBJECTIVE: To examine if older age (>70 years) should be a relative contraindication for heart transplantation, we evaluated the characteristics and outcomes of patients with age ≥70 years listed for heart transplantation; and whether post-transplantation survival was inferior to younger counterparts. DESIGN: Retrospective cohort analysis. SETTING: The scientific registry of transplant recipients (SRTR). PARTICIPANTS: Adults (≥18 years) listed for heart transplantation in the SRTR between 2000 and 2018. INTERVENTIONS: Heart transplantation. MEASUREMENTS: Characteristics and outcomes were compared for adults ≥70 years and <70 years. We evaluated waitlist mortality and post-transplant 1-year and 5-year survivals. RESULTS: The study included 57,285 patients (age range 18-79 years) listed for heart transplantation; 1203 (2.1%) age ≥70 years. Of these, 37,135 patients underwent heart transplantation; 806 (2.2%) were age ≥70 years. Yearly listing of those age ≥70 years has consistently increased from 2.5% (n = 30) in 2000 to 11% (n = 132) in 2017 (p < 0.01). As compared with the age <70 years group, those ≥70 years had a similar risk of death while waiting (sub-hazard ratio [SHR] 0.86, 95% confidence interval [HR] 0.68-1.08; p = 0.19) but were more likely to be transplanted (SHR 1.36, 95% CI 1.26-1.48; p < 0.01). Among the older patients, the overall post-transplant 1- and 5-year mortality rate was 10.4% and 19.2%, respectively. Older recipients had lower unadjusted survival compared with younger recipients (log-rank p = 0.03). However, after adjustment for relevant covariates, there was no significant difference in 5-year mortality between both groups (HR 1.06, 95% CI 0.91-1.254; p = 0.43). CONCLUSIONS: Post-transplant survival up to 5 years among patients of age ≥70 years was similar to that of younger recipients. Older patients who received heart transplantation appear to have lower risk features but receive hearts from higher risk donors. Chronologic age alone should not constitute a contraindication for heart transplantation, although careful patient selection criteria should be applied.

Aspiration thrombectomy in ST-Elevation myocardial infarction: Further insights from a network meta-analysis of randomized trials.

BACKGROUND: The initial enthusiasm for thrombectomy during percutaneous coronary intervention (PCI) of ST-elevation myocardial infarction (STEMI) patients has given way to restraint. There has been some limited interest whether it is beneficial in a few selected subgroups. Hence, we performed a network meta-analysis to compare conventional PCI (cPCI), Aspiration or manual thrombectomy (AT) and Mechanical thrombectomy (McT) for clarification. METHODS: Electronic databases were searched for randomized studies that compared AT, McT, or cPCI. A network meta-analysis was performed and odd's ratio (OR) with 95% confidence intervals was generated for major adverse cardiac events (MACE), mortality, myocardial infarction (MI), target vessel revascularization (TVR), stent thrombosis (ST), stroke, left ventricular ejection fraction (LVEF), myocardial blush grade (MBG) and ST segment resolution (STR). RESULTS: A total of 43 randomized trials (n = 26,682) were included. The risk of MACE (OR 0.86 95% CI 0.73-1.00), Mortality (OR 0.85 95% CI 0.73-0.99), MI (OR 0.65, 95% CI: 0.44-0.95) and TVR (OR 0.86, 95% CI: 0.74-1.00) were lower with AT compared to cPCI. The risk of ST and stroke was no different with the use of adjunctive AT. MBG, STR, and LVEF improved with the use of AT while the infarct size was no different in the two groups. CONCLUSIONS: Our comprehensive network meta-analysis suggests conflicting outcomes with AT. While Mortality, MACE, MI seem better, there is a suggestion that, Stroke and ST might be worse. Whether AT can still be pursued in any select cases should be further scrutinized.

An Observation of Racial and Gender Disparities in Congestive Heart Failure Admissions Using the National Inpatient Sample.

Background Congestive heart failure (CHF) is a frequent cause of inpatient admissions in the United States. The purpose of this study was to analyze the racial and gender disparities that occur in CHF admissions and determine the impact of these disparities on medical expenditure. Methods We analyzed the National Inpatient Sample (NIS) database from 2009 to 2014 for patients with a primary discharge diagnosis of CHF, and further stratified the cohort on the basis of race and sex. Multivariate analysis was performed to identify the association between CHF and total charges along with other variables such as mortality, length of stay (LOS), and number of procedures. Results There were a total of 5,491,050 admissions with a primary diagnosis of CHF from 977,850 in 2009 to 901,425 in 2014. Females accounted for 49.7%. Total charges for CHF admission were highest in Asians at an average cost of $59,668. African Americans had the lowest mortality rate at 1.75%, however, they also had an average age of admission of 63.47 years, compared to Caucasian at 76.76 (p<0.05). Total charges for males were $42,920 and $36,744 for females (p <0.05). Males also had more procedures at 1.16 vs 0.98 for females (p <0.05). Elixhauser mortality score was higher in males than females at 5.95 vs 5.42 (p <0.05). Conclusion Healthcare disparities exist in CHF admissions in both contexts of race and gender. Further studies are required to pinpoint the source of these differences not only to address mortality but also expenditure costs.

Patient Attributes Associated With Better Long-Term Outcomes on Palliative Milrinone.

Milrinone is a phosphodiesterase three inhibitor used as an inotrope in patients with advanced heart failure with reduced ejection fraction (HFrEF). Its action is independent of ß-receptor stimulation, which makes it preferable in patients who are on ß blockers as part of a guideline-directed neurohormonal blockade. There have been numerous studies evaluating the risks, benefits, and mortality associated with milrinone in the management of chronic heart failure patients. Time and again, there has been concern regarding the undesirable outcomes associated with it, including higher mortality and cardiac arrhythmias. Additionally, it has been difficult to determine whether milrinone or disease progression is responsible for adverse outcomes and mortality. In light of such discrepancy, the selection of patients for milrinone remains challenging. We hypothesized that there are underlying patient characteristics that influence the response to milrinone and may predict milrinone's adverse outcomes in spite of milrinone. A retrospective study review of 10 patients on palliative milrinone was conducted to identify these factors with a mean follow-up of 36 months. During the study period, four of 10 patients died. These four patients were on milrinone for a mean of 11.5 months. The attributes of the survivors compared to the deceased included lower age at start of therapy (67.5 vs 79 y), female gender (66% vs 33%), non-ischemic cardiomyopathy (33% vs 50%), associated diagnosis of atrial fibrillation/flutter(50% vs 25%), hyperlipidemia (66% vs 50%), or anemia (83% vs 75%), presence of chronic resynchronization therapy (CRT) (66% vs 25%), and implantable cardioverter-defibrillator (ICD) (16% vs 0%), as well as lower sodium (136 vs 140 mEq), chloride (101.5 vs 104.5 mEq), potassium (4.07 vs 4.23 mEq), and creatinine (1.3 vs 1.8 mg/dL)  Conversely, the deceased patients were more likely to have coronary artery disease (75% vs 33%), diabetes mellitus (50% vs 16%), hypertension (100% vs 83%), chronic kidney disease (75% vs 66%), peripheral vascular disease (25% vs zero), higher pulmonary artery pressures (54 vs 50.5%), and history of percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG) (50% vs 16%). These trends exhibit patient characteristics that may predict better outcomes on long-term milrinone although larger studies are needed to assess the statistical significance of these findings.

Methylenetetrahydrofolate Reductase Polymorphism and Premature Coronary Artery Disease.

Methylenetetrahydrofolate reductase (MTHFR) catalyzes the conversion of 5,10-methylenetetrahydrofolate to 5-methyltetrahydrofolate, a co-substrate for homocysteine re-methylation to methionine. Its deficiency leads to an increased serum level of homocysteine, which is well-known to be associated with premature coronary artery disease (CAD). Our case demonstrates the association of MTHFR polymorphism with premature CAD and myocardial infarction (MI) despite normal homocysteine levels. Screening for MTHFR polymorphisms in addition to homocysteine levels may be considered for patients presenting with premature CAD and a normal lipid profile. Aggressive risk reduction with lifestyle modifications and guideline-driven medical therapy supplementation might be necessary for secondary cardiovascular disease prevention until more specific therapeutic options are available for this subgroup of patients.

Metastatic squamous cell carcinoma to the heart: an unusual cause of ST elevation-a case report.

BACKGROUND: Cardiac tumours are typically secondary in nature, and the most common malignancies metastasizing to the heart are cancers of the lung, breast, oesophagus, melanoma, and lymphoma. We present a unique case of squamous cell carcinoma of the tongue, metastasizing to the heart and manifesting with ST elevation in the inferior-leads on electrocardiogram (ECG). CASE SUMMARY: A 25-year-old woman was initially diagnosed with squamous cell carcinoma of the tongue at the age of 23 and treated with hemi-glossectomy with clear-margins. Sixteen months later, the tumour recurred in the oropharynx and the left upper lobe of the lung. She was treated with chemotherapy; however, the tumour progressed. Thus, she was initiated on immunotherapy and radiation therapy. One month later, she presented with chest pain. Electrocardiogram revealed ST elevation in the inferior-leads. Troponin-I was elevated. Transthoracic echocardiogram revealed focal areas of thickening within the left and right ventricular myocardium with associated hypokinesis. These findings suggested ECG changes were likely secondary to infiltrative metastases and not acute-coronary-syndrome. Cardiac magnetic resonance imaging showed infiltrative masses with increased T2-signal and heterogeneous enhancement on perfusion and delayed enhancement sequences. Imaging also demonstrated numerous extra-cardiac metastases. She was treated with analgesics and discharged to home hospice. DISCUSSION: Head and neck cancers are a rare cause of cardiac metastasis. ST elevation and troponin release are thought to be due to tumour extension into the myocardium. Cardiac metastases usually present in patients with advanced widespread malignancy. In a cancer patient with cardiac symptoms or ECG changes, it is important to consider a broad differential diagnosis and entertain the possibility of cardiac metastasis.

Coronary Artery Aneurysms: Analysis of Comorbidities from the National Inpatient Sample.

Introduction Coronary artery aneurysms (CAA) are not commonly seen in the general population, with an incidence of approximately 0.37% to 2.53%. Patients are typically asymptomatic but symptomatic presentation varies from dyspnea and angina to myocardial infarction or even sudden cardiac death. Methods We conducted a retrospective analysis using the National Inpatient Sample Healthcare Cost and Utilization Project (NIS-HCUP) database to query individuals with the diagnosis of CAA with the International Classification of Disease (ICD) code 414.11 in all discharge diagnoses for the years 2006-2014. History of Kawasaki disease was determined by ICD code 446.1. Results From 2006 to 2014, there were 23,033 patients identified with CAA, correlating to approximately one case per 10,000 patients or an incidence of close to 0.01%. Of this, 1,405 or approximately 6.1% of these patients had Kawasaki disease. The mortality rate of CAA was 1.79%. In terms of demographics, Caucasians were the most likely to develop CAA, with 73.8% of cases. The mean age was 61.2 years, with a mean length of stay of 5.1 days. The average cost of admission was $70892. The presence of perivascular disease (15.5% vs 4.5% p<0.05), hypertension (66.1% vs 39.1% p<0.05), chronic lung disease (20.2% vs 15.1% p<0.05), diabetes (21.7% vs 15% p<0.05), renal failure (11% vs 8.8% p<0.05), coagulopathy (6.2% vs 3.4% p<0.05), and obesity (13.1% vs 8.2% p<0.05) were all risk factors for CAA as compared to those without. It was noted that weight loss (3.28% vs 1.91% p<0.05), electrolyte abnormalities (18.2% vs 15.5% p<0.05), and blood loss (2.1% vs 0.9% p<0.05) were protective of CAA. Conclusion CAA risk factors appear to be similar to those of coronary artery disease risk factors, with hypertension, diabetes, perivascular disease, and renal failure. Additionally, obesity was noted to be a risk factor but weight loss appeared to be protective. Interestingly, Kawasaki disease was seen at almost similar rates as these cardiac risk factors. The incidence of CAA we found, of almost 0.01%, is much less than in the quoted literature, however, previous studies did not have as many cases as our study.

Left ventricular apical hypertrophy in a transplanted heart: a case report.

BACKGROUND: Left ventricular apical hypertrophic cardiomyopathy is a rare presentation of hypertrophic cardiomyopathy associated with thickening of the apical segment of the left ventricle. It was initially described in Japan in 1976 and is characterized by electrocardiogram findings showing giant T wave inversions in the precordial leads as well as a spade shaped appearance of the apical cavity on imaging (Abugroun et al., Cardiol Res 8:265-268, 2017). In this case, we present a patient with a heart transplant with a stable post-transplant course who was found to have apical hypertrophic cardiomyopathy. There have been a few cases of apical hypertrophy in a transplanted heart documented in the literature. Making this case even more unique is that this presentation is evident 17 years after heart transplantation. CASE PRESENTATION: Fifty-four year-old male with a history of orthotropic heart transplant in 2001 on immunosuppressive therapy presented with palpitations and associated lightheadedness. He had a blood pressure of 184/89 mmHg on arrival but otherwise had stable vital signs and physical examination. Cardiac biomarkers revealed a CK of 59 U/L and a troponin of 0.11NG/ML(normal < 0.04NG/ML). B type natriuretic peptide was 371 PG/ML(normal 0-100PG/ML). Routine laboratory studies demonstrated normal sodium, magnesium, serum creatinine, and a potassium of 3.3 mmol/L(normal 3.5-5.1 mmol/L). His hemoglobin and hematocrit were normal. His EKG showed sinus rhythm with old T wave inversions in the anterior and lateral leads. Echocardiogram revealed a left ventricular ejection fraction of 55-65%, left posterior wall of 1.3 cm and interventricular septal wall 1.2 cm, thickened trabeculated apex, with severely dilated left atrium. He had a stress test that showed mild inferior wall thinning and a cardiac MRI performed to further evaluate apical hypertrophy revealed prominent apical hypertrophy of the left ventricle with near obliteration of the apical cavity. He had no events on cardiac monitoring and was discharged with close followup with the transplant team. CONCLUSION: While there are many etiologies of ApHCM, it has not been well described in transplanted patients who are on chronic immunosuppressive therapy. It is unclear if these groups of patients are at an increased risk of developing this condition. The literature suggests that ApHCM is associated with a being prognosis but there is new data suggesting increased mortality in a subset of patients with this condition.

Evaluation of a guideline directed medical therapy titration program in patients with heart failure with reduced ejection fraction.

INTRODUCTION: Heart failure is associated with recurrent hospitalizations and high mortality. Guideline directed medical treatment (GDMT), including beta blockers (BBs), angiotensin converting enzyme inhibitors (ACE-Is), angiotensin receptor blockers (ARBs) and aldosterone antagonists (AAs) has shown to improve outcomes. Current guidelines recommend the use of these medication classes at maximally tolerated dosages. Despite the evidence, < 25% of patients with heart failure with reduced left ventricular ejection fraction (HFrEF) are on the appropriate medical regimen titrated to the target doses. As such, we sought to assess the utility of a focused GDMT clinic to reduce this gap. METHODS: We conducted a retrospective chart review through existing patient data in a single center teaching hospital of patients referred to a focused GDMT clinic primarily staffed with heart failure trained nurse specialists, physician assistants and cardiologists. Management guidelines were developed with protocols for the initiation and uptitration of all therapeutic agents considered as GDMT.Our primary objective was to determine whether enrollment into a dedicated nursing led guideline directed medical therapy clinic would increase the proportion of patients with heart failure with reduced ejection fraction on appropriate medications as well as medication dosages in patients, the percentage of patients on the following medications and percentage at target doses: Renin-Angiotensin-Aldosterone System Blockers, Evidence Based Beta Blockers, and Aldosterone Antagonists. Our secondary objective was to determine if there was any clinical benefit on objective measures including renal function, hospital admissions, mortality and implantable defibrillator shocks. RESULTS: Between October 2015 and March 2017, 63 patients were identified by requisition forms, in which 61 were able to be identified based on legibility of identifying information. Mean duration of follow up was 264.44 ±â€¯162.68 days over 7 ±â€¯3.94 days. Mean ejection fraction was 21.8 ±â€¯7.3%. New onset cardiomyopathies (diagnosed within 30 days) compiled 21% of the patient population while those with demonstrated cardiomyopathies (> 90 days) compiled 48% of the patient population. Patients with NYHA class III heart failure compiled 65% of the patient population.There was a statistically significant increase in the mean number of GDMT at any dose (2.31 ±â€¯0.76 to 2.74 ±â€¯0.66; p < 0.001) and mean number of GDMT at target doses (0.54 ±â€¯0.79 to 1.52 ±â€¯1.1; p < 0.001). Percentage of the population that were on no target doses at initial visit was 62% which was reduced to 18% after intervention.Clinical improvement was reflected in significant improvement in ejection fraction from 21.8 ±â€¯7.8% to 36.2 ±â€¯14.3% (p < 0.001). Increases in sodium and chloride were statistically small but significant. There a significant reduction in heart failure hospitalizations in comparison to a year prior to after the initial encounter in the clinic (p < 0.001). CONCLUSION: This pilot study showed that a nurse directed GDMT titration program successfully increased the number of GDMT that patients were able to tolerate in a timely fashion, all the while enhancing ejection fraction, sodium and chloride levels, with a reduction in rehospitalization rates.

Updates in heart failure 30-day readmission prevention.

Heart failure (HF) and HF 30-day readmission rates have been a major focus of efforts to reduce health care cost in the recent era. Since the implementation of the Affordable Care Act (ACA) in 2012 and the Hospital Readmission Reduction Program (HRRP), concerted efforts have focused on reduction of 30-day HF readmissions and other admission diagnoses targeted by the HRRP. Hospitals and organizations have instituted wide-ranging programs to reduce short-term readmissions, but the data supporting these programs is often mixed. In this review, we will discuss the challenges associated with reducing HF readmissions and summarize the rationale and effect of specific programs on HF 30-day readmission rates, ranging from medical therapy and adherence to remote hemodynamic monitoring. Finally, we will review the effect that the focus on reducing 30-day HF readmissions has had on the care of the HF patient.

Prosthetic Tricuspid Valve Thrombosis.

Prosthetic valve thrombosis, a serious complication of prosthetic valve replacement, can be lethal without proper treatment. Right-sided valve thrombosis is rare but several therapeutic modalities can be considered: anticoagulation therapy, fibrinolysis, or surgery. Here, we report a case of significant tricuspid valve thrombosis which failed fibrinolytic therapy requiring repeat sternotomy with repeat tricuspid valve replacement with a porcine bioprosthesis.