Discordance between patient-predicted and model-predicted life expectancy among ambulatory patients with heart failure.

CONTEXT: Patients with chronic heart failure have impaired long-term survival, but their own expectations regarding prognosis have not been well studied. OBJECTIVES: To quantify expectations for survival in patients with heart failure, to compare patient expectations to model predictions, and to identify factors associated with discrepancies between patient-predicted and model-predicted prognosis. DESIGN, SETTING, AND PARTICIPANTS: Prospective face-to-face survey of patients from the single-center Duke Heart Failure Disease Management Program between July and December 2004, with follow-up through February 2008. Patient-predicted life expectancy was obtained using a visual analog scale. Model-predicted life expectancy was calculated using the Seattle Heart Failure Model. Actuarial-predicted life expectancy, based on age and sex alone, was calculated using life tables. Observed survival was determined from review of medical records and search of the Social Security Death Index. MAIN OUTCOME MEASURE: Life expectancy ratio (LER), defined as the ratio of patient-predicted to model-predicted life expectancy. RESULTS: The cohort consisted of 122 patients (mean age, 62 years; 47% African American, 42% New York Heart Association [NYHA] class III or IV). On average, patients overestimated their life expectancy relative to model-predicted life expectancy (median patient-predicted life expectancy, 13.0 years; model-predicted expectancy, 10.0 years). Median LER was 1.4 (interquartile range, 0.8-2.5). Younger age, increased NYHA class, lower ejection fraction, and less depression were the most significant predictors of higher LER. During a median follow-up of 3.1 years, 29% of the original cohort died. There was no association between higher LER and improved survival (adjusted hazard ratio for overestimated compared with concordant LER, 1.05; 95% confidence interval, 0.46-2.42). CONCLUSIONS: Ambulatory patients with heart failure tended to substantially overestimate their life expectancy compared with model-based predictions for survival. Because differences in perceived survival could affect decision making regarding advanced therapies and end-of-life planning, the causes of these discordant predictions warrant further study.

Topical anesthesia with EMLA reduces pain during endomyocardial biopsy: a randomized trial.

Cardiac transplant recipients often anticipate and suffer varying degrees of discomfort during surveillance endomyocardial biopsy (EMBx). We performed a randomized, blinded, placebo-controlled trial to determine whether topical anesthetic was associated with reduced pain and to identify factors associated with increased pain perception during EMBx. In 225 EMBxs, use of the eutectic mixture of lidocaine and prilocaine (EMLA) decreased pain score (-7.3 compared with placebo; p = 0.04); the other significant predictors of increased pain scores were time to achieve access (+2.3 per minute; p = 0.001) and female gender (+12.7 compared with males; p = 0.003). Topical anesthetic cream is associated with decreased pain during EMBx, even after adjusting for other predictors of pain, including female gender and longer time to achieve access. A better understanding of the factors affecting pain during EMBx could improve the comfort level of this procedure.

Outcomes with an alternate list strategy for heart transplantation.

BACKGROUND: Heart transplantation (HT) is an effective therapy for end-stage heart failure, but its impact is limited by the scarcity of donor organs and stringent selection criteria for both donors and recipients. The creation of an alternate list to match recipients with contraindications to traditional HT with sub-optimal donor organs has been implemented at some centers, but outcomes using this approach are uncertain. METHODS: We created an alternate list that matched recipients in whom standard HT was contraindicated with donor organs that had been rejected for use in standard transplantation. Data on patient characteristics and outcomes were compared with a control group of patients transplanted on the standard list over the same time period. RESULTS: Fifty patients received HT on the alternate list, compared with 195 on the standard list. The most common reasons for recipient listing on the alternate list were age >65 years (n = 28) and diabetes with end-organ dysfunction (n = 9). Alternate-list patients were older and more likely to have an ischemic etiology and diabetes mellitus. The most common reasons for allocation of donor organs to alternate-list patients were coronary artery disease (n = 12), positive hepatitis serology (n = 12) or left ventricular (LV) dysfunction (n = 8). Two-year survival was 70% for alternate-list patients compared with 88% for standard-list patients (p = 0.02). Post-transplant morbidity did not differ significantly between the 2 groups except that alternate-list patients were hospitalized more frequently. CONCLUSIONS: The use of an alternate list can expand the applicability of HT to patients who would otherwise be denied this therapy. Although associated with greater morbidity and mortality than standard-list HT, alternate-list HT resulted in clinical outcomes that were significantly better than the natural history of end-stage heart failure.

Recurrence of cardiac sarcoidosis in a heart transplant recipient.

We present the case of a young man who received a left ventricular assist device (LVAD) as a bridge to transplantation for end-stage heart failure, in whom the diagnosis of sarcoid cardiomyopathy was made at the time of LVAD implantation. He subsequently underwent uncomplicated heart transplantation. Nineteen months later, a routine surveillance endomyocardial biopsy specimen demonstrated recurrence of sarcoidosis in the transplanted heart.