Abstract 14420: Outcomes in Women With Cardiogenic Shock: Data From the Critical Care Cardiology Trial Network (CCCTN)

Circulation ◽  
2020 ◽  
Vol 142 (Suppl_3) ◽  
Author(s):  
Nicholas Phreaner ◽  
Haider Aldiwani ◽  
David Berg ◽  
Jeong-Gun Park ◽  
Jason N Katz ◽  
...  
Keyword(s):  
Hospital Mortality ◽  
Cardiogenic Shock ◽  
Mechanical Circulatory Support ◽  
Acute Decompensated Heart Failure ◽  
Decompensated Heart Failure ◽  
Circulatory Support ◽  
Study Group ◽  
Preserved Ejection Fraction ◽  
Pulmonary Artery Catheters ◽  
Cardiac Intensive Care

Introduction: Although sex-specific differences in treatment and outcomes of patients with acute myocardial infarction complicated by cardiogenic shock (AMICS) have been described, little is known about sex-specific differences in acute decompensated heart failure-related CS (ADHF-CS). Methods: The CCCTN is an investigator-initiated multicenter network of cardiac intensive care units (CICUs) in North America. Consecutive admissions (n=8240) to the CICU during annual snapshots (mostly 2 months) were submitted to the coordinating center (TIMI Study Group, Boston, MA). Patients were stratified by sex and type of CS. Adjustments were made for age and SOFA score. Results: Between 2017 and 2019, 1487 admissions were for CS of which 879 (33% women) were for ADHF-CS. In this cohort, age (median 62 y), race, and BMI (median 28 kg/m 2 ) did not differ by sex. Women and men also had similar SOFA and IABP-SHOCK II scores. Women were less likely to have CKD (28% vs 42%, p=<0.001) and CAD (28% vs 45%, p<0.001) but were significantly more likely to have underlying pulmonary disease (23% vs 15%, p<0.01). Although women and men had a similar burden of pre-existing HF (72% vs 75%, p=0.35), women were more likely to have HF with preserved ejection fraction (19% vs. 5%, p<0.001). Women had shorter CICU stays (4.0 vs 5.5 days, p<0.001), and numerically, though not significantly, lower use of pulmonary artery catheters (48% vs 53%, p=0.13) and mechanical circulatory support (28% vs 34%, p=0.11). In-hospital mortality in women with ADHF-CS was significantly higher than in men (39% vs 26%, p<0.001, adj-OR 2.05 (95% CI 1.47-2.86; p<0.001)). In contrast, in-hospital mortality for AMICS did not differ by sex (38% vs 40%, p=0.69). Conclusions: Compared to men, women admitted to the CICU with ADHF-CS had higher mortality despite similar indices of illness severity. The reason(s) behind this difference merit further study.

scholarly journals Implementation of a Cardiogenic Shock Team and Clinical Outcomes (INOVA-SHOCK Registry): Observational and Retrospective Study (Preprint)

2018 ◽  
Author(s):  
Behnam Tehrani ◽  
Alexander Truesdell ◽  
Ramesh Singh ◽  
Charles Murphy ◽  
Patricia Saulino
Keyword(s):  
Myocardial Infarction ◽  
Heart Failure ◽  
Acute Myocardial Infarction ◽  
Cardiogenic Shock ◽  
Clinical Outcomes ◽  
Mechanical Circulatory Support ◽  
Acute Decompensated Heart Failure ◽  
Survival Rates ◽  
Decompensated Heart Failure ◽  
Circulatory Support

BACKGROUND The development and implementation of a Cardiogenic Shock initiative focused on increased disease awareness, early multidisciplinary team activation, rapid initiation of mechanical circulatory support, and hemodynamic-guided management and improvement of outcomes in cardiogenic shock. OBJECTIVE The objectives of this study are (1) to collect retrospective clinical outcomes for acute decompensated heart failure cardiogenic shock and acute myocardial infarction cardiogenic shock, and compare current versus historical survival rates and clinical outcomes; (2) to evaluate Inova Heart and Vascular Institute site specific outcomes before and after initiation of the Cardiogenic Shock team on January 1, 2017; (3) to compare outcomes related to early implementation of mechanical circulatory support and hemodynamic-guided management versus historical controls; (4) to assess survival to discharge rate in patients receiving intervention from the designated shock team and (5) create a clinical archive of Cardiogenic Shock patient characteristics for future analysis and the support of translational research studies. METHODS This is an observational, retrospective, single center study. Retrospective and prospective data will be collected in patients treated at the Inova Heart and Vascular Institute with documented cardiogenic shock as a result of acute decompensated heart failure or acute myocardial infarction. This registry will include data from patients prior to and after the initiation of the multidisciplinary Cardiogenic Shock team on January 1, 2017. Clinical outcomes associated with early multidisciplinary team intervention will be analyzed. In the study group, all patients evaluated for documented cardiogenic shock (acute decompensated heart failure cardiogenic shock, acute myocardial infarction cardiogenic shock) treated at the Inova Heart and Vascular Institute by the Cardiogenic Shock team will be included. An additional historical Inova Heart and Vascular Institute control group will be analyzed as a comparator. Means with standard deviations will be reported for outcomes. For categorical variables, frequencies and percentages will be presented. For continuous variables, the number of subjects, mean, standard deviation, minimum, 25th percentile, median, 75th percentile and maximum will be reported. Reported differences will include standard errors and 95% CI. RESULTS Preliminary data analysis for the year 2017 has been completed. Compared to a baseline 2016 survival rate of 47.0%, from 2017 to 2018, CS survival rates were increased to 57.9% (58/110) and 81.3% (81/140), respectively (P=.01 for both). Study data will continue to be collected until December 31, 2018. CONCLUSIONS The preliminary results of this study demonstrate that the INOVA SHOCK team approach to the treatment of Cardiogenic Shock with early team activation, rapid initiation of mechanical circulatory support, hemodynamic-guided management, and strict protocol adherence is associated with superior clinical outcomes: survival to discharge and overall survival when compared to 2015 and 2016 outcomes prior to Shock team initiation. What may limit the generalization of these results of this study to other populations are site specific; expertise of the team, strict algorithm adherence based on the INOVA SHOCK protocol, and staff commitment to timely team activation. Retrospective clinical outcomes (acute decompensated heart failure cardiogenic shock, acute myocardial infarction cardiogenic shock) demonstrated an increase in current survival rates when compared to pre-Cardiogenic Shock team initiation, rapid team activation and diagnosis and timely utilization of mechanical circulatory support. CLINICALTRIAL ClinicalTrials.gov NCT03378739; https://clinicaltrials.gov/ct2/show/NCT03378739 (Archived by WebCite at http://www.webcitation.org/701vstDGd)

Abstract 15717: Impact of Mechanical Circulatory Support on Outcomes and In-hospital Mortality of Peripartum Cardiomyopathy Patients With Cardiogenic Shock: An Analysis of the Nis Database

Circulation ◽  
2020 ◽  
Vol 142 (Suppl_3) ◽  
Author(s):  
Jennifer Maning ◽  
Bertrand Ebner ◽  
Louis Vincent ◽  
Jelani Grant ◽  
Sunita Mahabir ◽  
...  
Keyword(s):  
Hospital Mortality ◽  
Cardiogenic Shock ◽  
Mechanical Circulatory Support ◽  
Peripartum Cardiomyopathy ◽  
Circulatory Support ◽  
Significant Difference ◽  
Baseline Characteristics ◽  
Similar Survival ◽  
Stage Renal Disease ◽  
End Stage

Background: Peripartum cardiomyopathy (PPCM) is an uncommon form of cardiomyopathy that affects young women at the end of pregnancy or in the first few months following delivery, and is associated with increased morbidity and mortality. In selected patients with cardiogenic shock (CS), mechanical circulatory support (MCS) devices improve outcomes. However, data comparing outcomes of patients with PPCM who develop CS and receive mechanical circulatory support (MCS) vs. those treated medically remains limited. Methods: Using the National Inpatient Database (NIS) we identified patients with PPCM who were treated for CS from 2012 to 2017. Primary outcome was in-hospital mortality. Multivariate analysis models were adjusted for statistically significant differences in baseline characteristics between the groups. Results: A total of 4686 patients were admitted with a diagnosis of PPCM, of these 199 patients developed cardiogenic shock. Only 50 (25.1%) patients received MCS. Patients who received MCS were less likely to have a prior ICD in place (6% vs. 23%, p = 0.008), and were more likely to suffer from end-stage renal disease (6% vs. 0.67%, p = 0.020). There were no other major differences in baseline characteristics among the two groups. The incidence of ICD implant prior to discharge (4% vs. 7.4%, p = 0.243, OR 0.39) and cardiac arrest (16% vs. 7.4%, p = 0.173, OR 2.01) was not significantly different between the groups. There was no significant difference in in-hospital mortality between those who received MCS devices and those treated medically (22% vs 10.1%, p = 0.256, OR 1.73). LOS was longer for the MCS group (23.2% vs. 13.4 mean days, p = 0.001). Conclusions: The use of MCS in PPCM patients who developed cardiogenic shock appears to offer similar survival benefit compared to those treated medically, despite being associated with longer length of stay This finding may be related to the complexity and acuity level of patients receiving MCS compared to those treated medically.

Heart Failure

2020 ◽  
Author(s):  
Sachin P Shah ◽  
Mandeep R. Mehra
Keyword(s):  
Heart Failure ◽  
Chronic Heart Failure ◽  
Ejection Fraction ◽  
Acute Decompensated Heart Failure ◽  
Heart Association ◽  
Decompensated Heart Failure ◽  
Advanced Heart Failure ◽  
Circulatory Support ◽  
Preserved Ejection Fraction ◽  
Reduced Ejection Fraction

Heart failure is a syndrome related to abnormal cardiac performance with a consequence of impaired cardiac output at rest or with exertion and/or congestion, which usually leads to symptoms of fatigue, dyspnea, and edema. The syndrome is characterized by various phenotypes related to a vast array of etiologies with diverse management targets. The current broad categorization of heart failure separates patients based on ejection fraction. Further description of the phenotype beyond ejection fraction is imperative to correctly identify the etiology of heart failure and, ultimately, to choose medical, device, and surgical therapies appropriately. This review covers the epidemiology of heart failure, defining the phenotype and etiology of heart failure, recognition and management of acute decompensated heart failure, management of chronic heart failure with a reduced ejection fraction, implantable cardioverter-defibrillators in heart failure with a reduced ejection fraction, management of heart failure with a preserved ejection fraction, and advanced heart failure. Figures show the evolution of therapy in chronic heart failure from the symptom-directed model, the complex pathophysiology and principal aberrations underlying heart failure with preserved ejection fraction, and concepts underlying surgical therapy in advanced heart failure using Laplace’s law. Tables list various etiologies of heart failure; sensitivity and specificity of clinical, biomarker, and radiographic data in the diagnosis of acute decompensated heart failure; drugs and devices with a demonstrated survival benefit in heart failure with a reduced ejection fraction; neurohormonal antagonist dosing in heart failure with a reduced ejection fraction; randomized, placebo-controlled trials in heart failure with a preserved ejection fraction; categorization of heart failure according to American Heart Association/American College of Cardiology heart failure stage, New York Heart Association functional class, and Interagency Registry for Mechanically Assisted Circulatory Support level; and poor prognostic indicators in heart failure. This review contains 4 highly rendered figures, 8 tables, and 114 references.

Heart Failure

2018 ◽  
Author(s):  
Sachin P Shah ◽  
Mandeep R. Mehra
Keyword(s):  
Heart Failure ◽  
Chronic Heart Failure ◽  
Ejection Fraction ◽  
Acute Decompensated Heart Failure ◽  
Heart Association ◽  
Decompensated Heart Failure ◽  
Advanced Heart Failure ◽  
Circulatory Support ◽  
Preserved Ejection Fraction ◽  
Reduced Ejection Fraction

Heart failure is a syndrome related to abnormal cardiac performance with a consequence of impaired cardiac output at rest or with exertion and/or congestion, which usually leads to symptoms of fatigue, dyspnea, and edema. The syndrome is characterized by various phenotypes related to a vast array of etiologies with diverse management targets. The current broad categorization of heart failure separates patients based on ejection fraction. Further description of the phenotype beyond ejection fraction is imperative to correctly identify the etiology of heart failure and, ultimately, to choose medical, device, and surgical therapies appropriately. This review covers the epidemiology of heart failure, defining the phenotype and etiology of heart failure, recognition and management of acute decompensated heart failure, management of chronic heart failure with a reduced ejection fraction, implantable cardioverter-defibrillators in heart failure with a reduced ejection fraction, management of heart failure with a preserved ejection fraction, and advanced heart failure. Figures show the evolution of therapy in chronic heart failure from the symptom-directed model, the complex pathophysiology and principal aberrations underlying heart failure with preserved ejection fraction, and concepts underlying surgical therapy in advanced heart failure using Laplace’s law. Tables list various etiologies of heart failure; sensitivity and specificity of clinical, biomarker, and radiographic data in the diagnosis of acute decompensated heart failure; drugs and devices with a demonstrated survival benefit in heart failure with a reduced ejection fraction; neurohormonal antagonist dosing in heart failure with a reduced ejection fraction; randomized, placebo-controlled trials in heart failure with a preserved ejection fraction; categorization of heart failure according to American Heart Association/American College of Cardiology heart failure stage, New York Heart Association functional class, and Interagency Registry for Mechanically Assisted Circulatory Support level; and poor prognostic indicators in heart failure. This review contains 3 highly rendered figures, 7 tables, and 113 references.

Sex differences in in-hospital mortality in acute decompensated heart failure with reduced and preserved ejection fraction

2012 ◽  
Vol 163 (3) ◽  
pp. 430-437.e3 ◽  
Author(s):  
Eileen M. Hsich ◽  
Maria V. Grau-Sepulveda ◽  
Adrian F. Hernandez ◽  
Eric D. Peterson ◽  
Lee H. Schwamm ◽  
...  
Keyword(s):  
Heart Failure ◽  
Sex Differences ◽  
Ejection Fraction ◽  
Hospital Mortality ◽  
Acute Decompensated Heart Failure ◽  
Decompensated Heart Failure ◽  
Preserved Ejection Fraction

scholarly journals Multidisciplinary approach and early use of percutaneous mechanical circulatory support devices in patients with cardiogenic shock

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
A Venuti ◽  
M Gramegna ◽  
L Baldetti ◽  
F Calvo ◽  
V Pazzanese ◽  
...  
Keyword(s):  
Heart Failure ◽  
Mortality Rate ◽  
Adverse Events ◽  
Hospital Mortality ◽  
Cardiogenic Shock ◽  
Mechanical Circulatory Support ◽  
Multidisciplinary Approach ◽  
Circulatory Support ◽  
Coronary Syndrome ◽  
Early Use

Abstract Background Despite progresses in the reperfusion strategies, the prognosis of patients with cardiogenic shock (CS) remains poor with a high in-hospital mortality rate. Percutaneous mechanical circulatory support systems (pMCS) reducing afterload, preload and myocardial oxygen demand, preventing compensatory tachycardia and increasing mean arterial pressure, lead to improve end-organ perfusion. Since CS progression to a refractory shock state is deleterious, timing of treatment represents a crucial issue in these patients. Purpose The aim of our study was to assess whether a multidisciplinary approach and an early use of pMCS could be safe and effective in improving CS patients' outcome. Methods We examined the outcome in terms of one-month survival of 62 patients (75.8% males, mean age 67.7±12.2 years) admitted between January and December 2018 to our Cardiac Intensive Care Unit (CICU) with cardiogenic shock due to acute coronary syndrome (ACS), acute heart failure (AHF) and other causes in 43.5%, 21.6%, 35.4% of cases respectively. For each patient, a Multidisciplinary Shock Team (CS-Team) including critical care specialists, interventional cardiologists and advanced heart failure specialists, was involved and the early use of pMCS was considered. Results Overall, 52 (83.9%) CS patients underwent pMCS implant, including intra-aortic ballon pump counterpulsation (IABP), Impella system (Impella), venous-arterial extracorporeal membrane oxygenation (VA ECMO) in 67.7%, 46.7%, 11.3% of cases respectively. Median time from the first CS-Team contact to the pMCS implantation was 32.5 (30–60) minutes. Among ACS-CS group, AHF-CS group and CS-due to other causes group, pMCS were implanted in 25 (92.5%), 12 (92.3%) and 15 (68.1%) patients respectively. Lower extremities ischemia, gastrointestinal/intracerebral and life-threatening bleeding and ischemic stroke were observed as pMCS related adverse events in 9.7%, 6.4%, 1.6%, 3.2%, 6.4% of cases respectively. At one month, 56 (90.3%) CS patients were discharged alive while 6 (9.7%) CS patients died during the CICU stay. Conclusion A multidisciplinary approach of CS patients, contemplating an early and extensive use of pMCS, may be effective in the reduction of in-hospital mortality rate with a low and acceptable occurrence of pMCS related adverse events. Funding Acknowledgement Type of funding source: None

scholarly journals Clinical Outcomes Associated with Acute Mechanical Circulatory Support Utilization in Heart Failure Related Cardiogenic Shock

2021 ◽  
Author(s):  
Jaime Hernandez-Montfort ◽  
Shashank S. Sinha ◽  
Katherine L. Thayer ◽  
Evan H. Whitehead ◽  
Mohit Pahuja ◽  
...  
Keyword(s):  
Heart Failure ◽  
Hospital Mortality ◽  
Cardiogenic Shock ◽  
Clinical Outcomes ◽  
Mechanical Circulatory Support ◽  
Left Ventricular ◽  
Right Atrial ◽  
Circulatory Support ◽  
Hospital Death ◽  
Acute Mechanical Circulatory Support

Background : Cardiogenic shock occurring in the setting of advanced heart failure (HF-CS) is increasingly common. However, recent studies have focused almost exclusively on acute myocardial infarction related cardiogenic shock. We sought to define clinical, hemodynamic, metabolic, and treatment parameters associated with clinical outcomes among HF-CS patients, using data from the Cardiogenic Shock Working Group (CSWG) Registry. Methods : Patients with HF-CS were identified from the multi-center CSWG registry and divided into 3 outcome categories assessed at hospital discharge: mortality, heart replacement therapy (HRT: durable ventricular assist device [VAD] or orthotopic heart transplant [OHT]), or native heart survival (NHS). Clinical characteristics, hemodynamic, laboratory parameters, drug therapies, acute mechanical circulatory support device (AMCS) utilization, and Society of Cardiovascular Angiography and Intervention (SCAI) stages were compared across the 3 outcome cohorts. Results : Of the 712 HF-CS patients identified, 180 (25.3%) died during their index admission, 277 (38.9%) underwent HRT (durable VAD or OHT), and 255 (35.8%) experienced NHS without HRT. Patients who died had the highest right atrial pressure and heart rate and the lowest mean arterial pressure of the 3 outcome groups (p<0.01 for all). Biventricular and isolated left-ventricular congestion were common among patients who died or underwent HRT, respectively. Lactate, blood urea nitrogen, serum creatinine, and aspartate aminotransferase were highest in HF-CS patients experiencing in-hospital death. Intra-aortic balloon pump (IABP) was the most commonly used AMCS device in the overall cohort and among patients receiving HRT. Patients receiving more than one AMCS device had the highest in-hospital mortality rate irrespective of the number of vasoactive drugs used. Mortality decreased with deteriorating SCAI stages (stage B: 0%, stage C: 10.7%, stage D: 29.4%, stage E: 54.5%, 1-way ANOVA = <0.001). Conclusions : Patients with HF-CS experiencing in-hospital mortality had a high prevalence of biventricular congestion and markers of end-organ hypoperfusion. Substantial heterogeneity exists with use of AMCS in HF-CS with IABP being the most common device used and high rates of in-hospital mortality after exposure to more than one AMCS device.

Abstract 114: Mechanical Circulatory Support in Percutaneous Coronary Intervention: A Propensity-matched Analysis

2015 ◽  
Vol 8 (suppl_2) ◽  
Author(s):  
Rohan Khera ◽  
Peter Cram ◽  
Mary Vaughan-Sarrazin ◽  
Phillip A Horwitz ◽  
Saket Girotra
Keyword(s):  
Percutaneous Coronary Intervention ◽  
High Risk ◽  
Hospital Mortality ◽  
Cardiogenic Shock ◽  
Mechanical Circulatory Support ◽  
Clinical Effectiveness ◽  
Coronary Intervention ◽  
Ventricular Assist Devices ◽  
Circulatory Support ◽  
Percutaneous Coronary

Introduction: Percutaneous ventricular assist devices (PVAD) and intra-aortic balloon pump (IABP) are used to provide mechanical circulatory support for high-risk percutaneous coronary intervention (PCI). Due to limited evidence from randomized controlled trials, we compared clinical outcomes between PVAD and IABP in PCI patients using a propensity-matched analysis. Methods: Adult patients who underwent PCI during 2004-2012 and also received either a PVAD or an IABP on the same day as PCI were identified in the National Inpatient Sample using ICD9 procedure codes. We compared in-hospital mortality for PVAD vs. IABP using a 1:2 propensity-matched analysis - both overall and in subgroups with cardiogenic shock, AMI without cardiogenic shock and no cardiogenic shock or AMI. Results: We identified 5031 patients who received a PVAD and 122,333 who received an IABP on the same day as PCI. Patients who received PVAD were older (69 vs 65 years), more likely to be men (74% vs 69%), admitted electively (30% vs 11%) but less likely to have AMI (52% vs 90%), cardiogenic shock (23% vs 50%), cardiac arrest (12% vs 25%) or need mechanical ventilation (16% vs 29%) compared to IABP patients (P<0.001 for all). In contrast, prevalence of heart failure (68% vs 41%), valvular heart disease (22% vs 13%), chronic kidney disease (27% vs 11%), hypertension (71% vs 56%) and diabetes (46% vs 32%) was higher in PVAD recipients (P<0.001 for all). Unadjusted in-hospital mortality in PVAD recipients was lower compared to IABP patients - both overall (12.8% vs 20.9%, P<0.001) and in the cardiogenic shock subgroup (31% vs 38%, P=0.04) but was similar in patients without cardiogenic shock. After propensity-matching and successful balancing of covariates (figure) we found no difference in mortality in PVAD and IABP recipients (odds ratio [OR] 0.88, 95% CI 0.70-1.09). Our findings were also consistent among patients with cardiogenic shock (OR 1.37, 95% CI 0.99-1.90), AMI without cardiogenic shock (OR 0.72, 95% CI 0.46-1.14) and no cardiogenic shock or AMI (OR 0.54, 95% CI 0.27-1.06). Conclusion: The lower unadjusted mortality in patients undergoing PCI with PVAD support compared to IABP support may be due to selective use of PVADs in a lower risk population. Randomized trials are necessary to establish the clinical effectiveness of PVADs to support high-risk PCI.

Heart Failure

2020 ◽  
Author(s):  
Sachin P Shah ◽  
Mandeep R. Mehra
Keyword(s):  
Heart Failure ◽  
Chronic Heart Failure ◽  
Ejection Fraction ◽  
Acute Decompensated Heart Failure ◽  
Heart Association ◽  
Decompensated Heart Failure ◽  
Advanced Heart Failure ◽  
Circulatory Support ◽  
Preserved Ejection Fraction ◽  
Reduced Ejection Fraction

Heart failure is a syndrome related to abnormal cardiac performance with a consequence of impaired cardiac output at rest or with exertion and/or congestion, which usually leads to symptoms of fatigue, dyspnea, and edema. The syndrome is characterized by various phenotypes related to a vast array of etiologies with diverse management targets. The current broad categorization of heart failure separates patients based on ejection fraction. Further description of the phenotype beyond ejection fraction is imperative to correctly identify the etiology of heart failure and, ultimately, to choose medical, device, and surgical therapies appropriately. This review covers the epidemiology of heart failure, defining the phenotype and etiology of heart failure, recognition and management of acute decompensated heart failure, management of chronic heart failure with a reduced ejection fraction, implantable cardioverter-defibrillators in heart failure with a reduced ejection fraction, management of heart failure with a preserved ejection fraction, and advanced heart failure. Figures show the evolution of therapy in chronic heart failure from the symptom-directed model, the complex pathophysiology and principal aberrations underlying heart failure with preserved ejection fraction, and concepts underlying surgical therapy in advanced heart failure using Laplace’s law. Tables list various etiologies of heart failure; sensitivity and specificity of clinical, biomarker, and radiographic data in the diagnosis of acute decompensated heart failure; drugs and devices with a demonstrated survival benefit in heart failure with a reduced ejection fraction; neurohormonal antagonist dosing in heart failure with a reduced ejection fraction; randomized, placebo-controlled trials in heart failure with a preserved ejection fraction; categorization of heart failure according to American Heart Association/American College of Cardiology heart failure stage, New York Heart Association functional class, and Interagency Registry for Mechanically Assisted Circulatory Support level; and poor prognostic indicators in heart failure. This review contains 4 highly rendered figures, 8 tables, and 114 references.

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