Comprehensive Pharmacologic Management Strategies for Heart Failure

Abstract Purpose A case of uncontrolled hypertension nonresponsive to traditional pharmacologic management in a pediatric patient with a ventricular assist device awaiting a heart transplant is reported. Summary A 4-month-old male in heart failure was experiencing uncontrolled hypertension. Because of a lack of hemodynamic stability, he was unable to be listed as a heart transplant candidate. He received multiple antihypertensive agents (calcium channel blockers, β-blockers, and direct-acting vasodilators) as both intermittent and continuous infusions over the course of several days without achieving normotension. The decision was then made to administer intravenous phentolamine as a continuous infusion to pursue a different mechanism than with traditional antihypertensive agents to achieve hemodynamic stability. Within 8 hours of initiation of the continuous phentolamine infusion, the patient became normotensive and was listed for a heart transplant. The continuous phentolamine infusion was administered over the next 4 days to maintain normotension, and on day 4 the patient underwent successful orthotopic heart transplantation. Conclusion A 4-month-old male in heart failure with a ventricular assist device, experiencing uncontrolled hypertension nonresponsive to traditional pharmacologic management, was successfully treated with a continuous intravenous infusion of phentolamine.

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Abstract 14647: Stress Echocardiography Predicts Heart Failure Progression and Alters Management Strategies in Patients with Hypertrophic Cardiomyopathy

Circulation ◽

10.1161/circ.130.suppl_2.14647 ◽

2014 ◽

Vol 130 (suppl_2) ◽

Author(s):

Ethan J Rowin ◽

Barry J Maron ◽

Iacopo Olivotto ◽

Susan A Casey ◽

Anna Arretini ◽

...

Keyword(s):

Heart Failure ◽

Nyha Class ◽

Management Strategies ◽

Left Ventricular ◽

Advanced Heart Failure ◽

Outflow Tract ◽

Class I ◽

Class Iii ◽

Outflow Obstruction ◽

Heart Failure Progression

Background: One-third of HCM patients without left ventricular outflow tract obstruction under resting conditions have the propensity to develop an outflow gradient with physiologic exercise. However, the natural history and management implications of exercise-induced (i.e., provocable) obstruction is unresolved. Methods: We prospectively studied 533 consecutive HCM patients without outflow obstruction at rest (<30mmHg) who underwent a symptom limiting stress (exercise) echocardiogram to assess development of outflow obstruction following physiologic provocation and followed for 6.5 ± 2.0 years. Of the 533 patients, obstruction ≥ 30 mmHg was present following exercise in 262 patients (49%; provocable obstruction), and was absent both at rest and with exercise in 271 (51%; nonobstructive). Results: Over the follow-up period, 43 out of 220 (20%) HCM patients with provocable obstruction and baseline NYHA class I/II symptoms developed progressive limiting heart failure symptoms to class III/IV, compared to 24 of 249 (10%) nonobstructive patients. Rate of heart failure progression was significantly greater in patients with provocable obstruction vs. nonobstructive patients (3.1%/year vs. 1.5%/year; RR=2.0, 95% CI of 1.3-3.2; p=0.003). However, the vast majority of patients with provocable obstruction who developed advanced heart failure symptoms achieved substantial improvement in symptoms to class I / II following relief of obstruction with invasive septal reduction therapy (n=30/32; 94%). In comparison, the majority of nonobstructive patients who developed advanced heart failure remained in class III/IV (16/24;67%), including 10 (42%) currently listed for heart transplant. Conclusions: Stress (exercise) echocardiogram identifies physiological provocable outflow tract obstruction in HCM, and is a predictor of future risk for progressive heart failure (3.1%/year), in patients who become candidates for invasive septal reduction therapy. Therefore, exercise echocardiography should be considered in all HCM patients without obstruction under resting conditions.

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Pharmacologic Management for Heart Failure and Emerging Therapies

Current Cardiology Reports ◽

10.1007/s11886-017-0899-x ◽

2017 ◽

Vol 19 (10) ◽

Cited By ~ 5

Author(s):

Diana H. Kim ◽

Feng-Ju Chien ◽

Howard J. Eisen

Keyword(s):

Heart Failure ◽

Emerging Therapies ◽

Pharmacologic Management

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Management Strategies in Atrial Fibrillation in Patients With Heart Failure

Cardiology in Review ◽

10.1097/crd.0b013e31825dcf9b ◽

2012 ◽

Vol 20 (6) ◽

pp. 288-296 ◽

Cited By ~ 3

Author(s):

Amir Y. Shaikh ◽

Abhishek Maan ◽

E. Kevin Heist ◽

Dennis A. Tighe ◽

Gerard P. Aurigemma ◽

...

Keyword(s):

Heart Failure ◽

Atrial Fibrillation ◽

Management Strategies ◽

Patients With Heart Failure

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Pharmacologic Management of Heart Failure in the Ambulatory Setting

Cardiovascular Therapeutics: A Companion to Braunwald's Heart Disease ◽

10.1016/b978-1-4557-0101-8.00012-6 ◽

2013 ◽

pp. 241-269 ◽

Cited By ~ 1

Author(s):

Michael M. Givertz ◽

Jay N. Cohn

Keyword(s):

Heart Failure ◽

Ambulatory Setting ◽

Pharmacologic Management

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Heart failure with preserved ejection fraction: controversies, challenges and future directions

Heart ◽

10.1136/heartjnl-2016-310790 ◽

2018 ◽

Vol 104 (5) ◽

pp. 377-384 ◽

Cited By ~ 37

Author(s):

Rosita Zakeri ◽

Martin R Cowie

Keyword(s):

Heart Failure ◽

Ejection Fraction ◽

Management Strategies ◽

Cyclic Guanosine Monophosphate ◽

Guanosine Monophosphate ◽

Protein Kinase G ◽

Preserved Ejection Fraction ◽

Future Directions ◽

Novel Treatments ◽

Inflammatory State

Heart failure with preserved ejection fraction (HFpEF) comprises almost half of the population burden of HF. Because HFpEF likely includes a range of cardiac and non-cardiac abnormalities, typically in elderly patients, obtaining an accurate diagnosis may be challenging, not least due to the existence of multiple HFpEF mimics and a newly identified subset of patients with HFpEF and normal plasma natriuretic peptide concentrations. The lack of effective treatment for these patients represents a major unmet clinical need. Heterogeneity within the patient population has triggered debate over the aetiology and pathophysiology of HFpEF, and the neutrality of randomised clinical trials suggests that we do not fully understand the syndrome(s). Dysregulated nitric oxide–cyclic guanosine monophosphate–protein kinase G signalling, driven by comorbidities and ageing, may be the fundamental abnormality in HFpEF, resulting in a systemic inflammatory state and microvascular endothelial dysfunction. Novel informatics platforms are also being used to classify HFpEF into subphenotypes, based on statistically clustered clinical and biological characteristics: whether such subclassification will lead to more targeted therapies remains to be seen. In this review, we summarise current concepts and controversies, and highlight the diagnostic and therapeutic challenges in clinical practice. Novel treatments and disease management strategies are discussed, and the large gaps in our knowledge identified.

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A multiparametric ICD algorithm for heart failure risk stratification and management: an analysis in clinical practice

EP Europace ◽

10.1093/europace/euab116.468 ◽

2021 ◽

Vol 23 (Supplement_3) ◽

Author(s):

L Calo" ◽

V Bianchi ◽

D Ferraioli ◽

L Santini ◽

A Dello Russo ◽

...

Keyword(s):

Heart Failure ◽

At Risk ◽

Clinical Practice ◽

Risk Stratification ◽

Management Strategies ◽

Cardiac Resynchronization ◽

Office Visits ◽

Increased Risk ◽

Patients At Risk ◽

Observation Period

Abstract Funding Acknowledgements Type of funding sources: None. Introduction The HeartLogic algorithm combines multiple implantable cardioverter defibrillator (ICD) sensors to identify patients at risk of heart failure (HF) events. Purpose We sought to evaluate the risk stratification ability of this algorithm in clinical practice. We also analyzed the alert management strategies adopted in the study group and their association with the occurrence of HF events. Methods The HeartLogic feature was activated in 366 ICD and cardiac resynchronization therapy ICD patients at 22 centers. The HeartLogic algorithm automatically calculates a daily HF index and identifies periods IN or OUT of an alert state on the basis of a configurable threshold (in this analysis set to 16). Results The HeartLogic index crossed the threshold value 273 times (0.76 alerts/patient-year) in 150 patients over a median follow-up of 11 months [25-75 percentile: 6-16]. Overall, the time IN the alert state was 11% of the total observation period. Patients experienced 36 HF hospitalizations and 8 patients died of HF (rate: 0.12 events/patient-year) during the observation period. Thirty-five events were associated with the IN alert state (0.92 events/patient-year versus 0.03 events/patient-year in the OUT of alert state). The hazard ratio in the IN/OUT of alert state comparison was (HR: 24.53, 95% CI: 8.55-70.38, p < 0.001), after adjustment for baseline clinical confounders. Alerts followed by clinical actions were associated with a lower rate of HF events (HR: 0.37, 95% CI: 0.14-0.99, p = 0.047). No differences in event rates were observed between in-office and remote alert management. By contrast, verification of HF symptoms during post-alert examination was associated with a higher risk of HF events (HR: 5.23, 95% CI: 1.98-13.83, p < 0.001). Conclusions This multiparametric ICD algorithm identifies patients during periods of significantly increased risk of HF events. The rate of HF events seemed lower when clinical actions were undertaken in response to alerts. Extra in-office visits did not seem to be required in order to effectively manage HeartLogic alerts, while post-alert verification of symptoms seemed useful in order to better stratify patients at risk of HF events.

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Abstract 16766: Intraprocedural Ablation and Fluid Status Management in Heart Failure Patients Undergoing Catheter Ablation for Atrial Fibrillation

Circulation ◽

10.1161/circ.142.suppl_3.16766 ◽

2020 ◽

Vol 142 (Suppl_3) ◽

Author(s):

Sahitya Allam ◽

Evan Harmon ◽

Sula Mazimba ◽

James M Mangrum ◽

Ilana Kutinsky ◽

...

Keyword(s):

Heart Failure ◽

Atrial Fibrillation ◽

Catheter Ablation ◽

Tertiary Care ◽

Fluid Management ◽

Management Strategies ◽

Clinical Trial Data ◽

Posterior Wall ◽

Fluid Status ◽

Volume Output

Background: Recent randomized clinical trial data has supported catheter ablation (CA) of atrial fibrillation (AF) in patients with heart failure (HF). Ablation and fluid management strategies could impact periprocedural outcomes especially in HF patients. Methods: We conducted a single-center retrospective analysis of 200 consecutive patients with and without HF undergoing CA at a tertiary care academic center from July 2017 through June 2018. HF was defined as any EF < 40%, prior inpatient admission for HF exacerbation, or ambulatory management of HF confirmed by independent chart review. Diuretic regimens were reported as furosemide equivalent. Results: Among 200 patients, 65 (32.5%) had HF and 135 (67.5%) did not. HF patients had longer mean procedure times (299.8 ± 96 min vs 268.4 ± 96 min, p = 0.03) and were more likely to require mitral isthmus (p < 0.001), posterior wall isolation (p = 0.002), and cavotriscupid isthmus (p = 0.004) ablations. There were no differences between the HF vs. non-HF groups’ intraprocedural volume intake, intraprocedural volume output, net fluid status, or intraprocedural diuretic dose (Table 1). HF patients received higher doses of IV (41.5 ± 43.0 mg vs 23.6 ± 11.8 mg, p = 0.007) and PO (43.2 ± 16.7 mg vs 26.7 ± 10.0 mg, p < 0.001) postprocedural diuretic. There were no differences in the rates of major in-hospital complications (Table 1). In a multivariable regression analysis adjusted for procedural covariates, there were higher proportions of posterior wall isolation (p = 0.01) as well as postprocedural PO (p = 0.01) and IV diuretic (p = 0.002) administration in the HF cohort. Conclusion: Intraprocedural volume and diuretic management was similar between HF and non-HF patients undergoing CA of AF, though HF patients tended to receive more aggressive diuresis post procedurally with no difference in complications. Table 1. Intra- and post-procedural management and outcomes in HF vs non-HF patients undergoing CA for AF

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Protecting the most vulnerable during COVID-19 and beyond: a case report on the remote management of heart failure patients with cardiac implantable electronic devices

European Heart Journal - Case Reports ◽

10.1093/ehjcr/ytaa249 ◽

2020 ◽

Vol 4 (FI1) ◽

pp. 1-6

Author(s):

Fozia Zahir Ahmed ◽

Carol Crosbie ◽

Matthew Kahn ◽

Manish Motwani

Keyword(s):

Heart Failure ◽

High Risk ◽

Electronic Devices ◽

Management Strategies ◽

Phone Call ◽

Cardiac Resynchronization ◽

Physiological Data ◽

Increased Risk

Abstract Background Heart failure (HF) patients with cardiac implantable electronic devices (CIEDs) represent an important cohort. They are at increased risk of hospitalization and mortality. We outline how remote-only management strategies, which leverage transmitted health-related data, can be used to optimize care for HF patients with a CIED during the COVID-19 pandemic. Case summary An 82-year-old man with HF, stable on medical therapy, underwent cardiac resynchronization therapy implantation in 2016. Modern CIEDs facilitate remote monitoring by providing real-time physiological data (thoracic impedance, heart rate and rhythm, etc.). The ‘Triage Heart Failure Risk Score’ (Triage-HFRS), available on Medtronic CIEDs, integrates several monitored physiological parameters into a risk prediction model classifying patients as low, medium, or high risk of HF events within 30 days. In November 2019, the patient was enrolled in an innovative clinical pathway (Triage-HF Plus) whereby any ‘high’ Triage-HF risk status transmission prompts a phone call-based virtual consultation. A high-risk alert was received via remote transmission on 11 March, triggering a phone call assessment. Upon reporting increasing breathlessness, diuretics were initiated. The prescription was remotely issued and delivered to the patient’s home. This approach circumvented the need for all face-to-face reviews, delivering care in an entirely remote manner. Discussion The challenges posed by COVID-19 have prompted us to think differently about how we deliver care for patients, both now and following the pandemic. Contemporary CIEDs facilitate the ability to remotely monitor HF patients by providing rich physiological data that can help identify individuals at elevated risk of decompensation using automated device-generated alerts.

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