Faculty Bibliography

Reduced parasympathetic modulation of heart rate is an independent predictor of mortality in heart failure. It is not known whether enhancing parasympathetic outflow to the heart impacts survival in these patients. Our aim was to evaluate whether the neck collar technique, a noninvasive method of stimulating the carotid baroreceptors, was a reliable and reproducible means to evaluate baroreflex control of heart rate in patients with heart failure. Twenty-five patients (20 males, mean age 54 +/-10-years) with symptomatic heart failure (NYHA class II-III) were studied on two separate days, one week apart. All were free of cholesterol plaques in the carotid arteries. Blood pressure and RR intervals were measured continuously in the seated position. Graded pressure (-70 to +70 mmHg) was administered to the neck during a held expiration using a custom-designed collar. Maximum change in RR intervals was determined during the onset of neck pressure. Stimulus response curves were plotted for changes in RR intervals against estimated-carotid sinus pressure. The technique was well tolerated and there were no adverse events. The maximal differential, used to estimate baroreflex gain, was tightly correlated between visits 1 and 2 (R2= 0.8063, p < 0.0001). The corresponding "set point" of the reflex was also significantly correlated between visits (R2=0.3324 p=0.049). To our knowledge, this is the first time the neck collar technique has been validated in a medically fragile population. The technique is safe and reproducible and maybe useful to help understand whether strategies that enhance parasympathetic activity change outcomes in heart failure

Physical activity and cardiac rehabilitation (CR) are components of heart failure (HF) self-care. The aims of this study were to describe patterns of physical activity in African Americans (n = 30) with HF and to explore experience in CR. This was a mixed method, concurrent nested, predominantly qualitative study. Qualitative data were collected via interviews exploring typical physical activity, and CR experience. It was augmented by quantitative data measuring HF severity, self-care, functional capacity and depressive symptoms. Mean age was 60 +/- 15 years; 65% were New York Heart Association (NYHA) class III HF. Forty-three percent reported that they did less than 30 min of exercise in the past week; 23% were told "nothing" about exercise by their provider, and 53% were told to do "minimal exercise". A measure of functional capacity indicated the ability to do moderate activity. Two related themes stemmed from the narratives describing current physical activity: "given up" and "still trying". Six participants recalled referral to CR with one person participating. There was high concordance between qualitative and quantitative data, and evidence that depression may play a role in low levels of physical activity. Findings highlight the need for strategies to increase adherence to current physical activity guidelines in this older minority population with HF.

The presentation, natural history, clinical outcomes, and response to therapy in patients with heart failure differ in some ways across populations. Women, older adults, and non-Caucasian racial or ethnic groups compose a substantial proportion of the overall heart failure population, but they have typically been underrepresented in clinical trials. As a result, uncertainty exists about the efficacy of some guideline-directed medical therapies and devices in specific populations, which may result in the under- or overtreatment of these patients. Even when guideline-based treatments are prescribed, socioeconomic, physical, or psychologic factors may affect non-Caucasian and older adult patient groups to a different extent and affect the application, effectiveness, and tolerability of these therapies. Individualized therapy based on tailored biology (genetics, proteomics, metabolomics), socioeconomic and cultural considerations, and individual goals and preferences may be the optimal approach for managing diverse patients. This comprehensive approach to personalized medicine is evolving, but in the interim, the scientific community should continue efforts focused on intensifying research in special populations, prescribing guideline-directed medical therapy unless contraindicated, and implementing evidence-based strategies including patient and family education and multidisciplinary team care in the management of patients.

Background: Comorbid diabetes is common in heart failure and associated with increased hospitalization and mortality. Nonetheless, the optimal treatment strategy for diabetes in heart failure patients remains poorly characterized, particularly among low income and minority populations. The purpose of this study was to evaluate the association between glycemic control and outcomes among patients with heart failure and diabetes who were seen in a safety net health care system. Methods: We performed a retrospective cohort study of outpatients with heart failure and diabetes in the New York City Health and Hospitals Corporation, the largest municipal health care system in the United States. Subjects with diagnoses of heart failure and diabetes mellitus were included if they had an outpatient visit in 2007-2010 with an HbA1c performed in the prior 90 days. HbA1c and covariates, including demographics, comorbidities, vital signs, labs, and prior utilization, were obtained from the HHC data warehouse, which was linked to the New York State Inpatient Database and to New York State Vital Statistics to ascertain hospitalization and mortality events, respectively. Cox proportional hazard models were used to measure the association between HbA1c levels and outcomes of all-cause hospitalization, heart failure hospitalization, and mortality. Results: Of 4,723 patients with heart failure and diabetes, 42.6% were black, 30.5% were Hispanic/ Latino, 31.4% were Medicaid beneficiaries and 22.9% were uninsured. As compared to patients with an HbA1c of 8.0-8.9%, patients with an HbA1c of <6.5%, 6.5-6.9%, 7.0-7.9%, and >9.0% had an adjusted hazard ratio (aHR) (95% CI) for all-cause hospitalization of 1.03 (0.90-1.17), 1.05 (0.91-1.22), 1.03 (0.90-1.17), and 1.13 (1.00-1.28), respectively. An HbA1c>9.0% was also associated with an increased risk of heart failure hospitalization (aHR 1.33; 95% CI 1.11- 1.59) and a non-significant increased risk in mortality (aHR 1.20; 95% CI 0.99-1.45) when compared to HbA1c of 8.0-8.9%. Conclusions: Among a cohort of primarily minority and low income patients with heart failure and diabetes, an increased risk of hospitalization was observed only for an HbA1c greater than 9%

We propose that stage D advanced heart failure be defined as the presence of progressive and/or persistent severe signs and symptoms of heart failure despite optimized medical, surgical, and device therapy. Importantly, the progressive decline should be primarily driven by the heart failure syndrome. Formally defining advanced heart failure and specifying when medical and device therapies have failed is challenging, but signs and symptoms, hemodynamics, exercise testing, biomarkers, and risk prediction models are useful in this process. Identification of patients in stage D is a clinically important task because treatments are inherently limited, morbidity is typically progressive, and survival is often short. Age, frailty, and psychosocial issues affect both outcomes and selection of therapy for stage D patients. Heart transplant and mechanical circulatory support devices are potential treatment options in select patients. In addition to considering indications, contraindications, clinical status, and comorbidities, treatment selection for stage D patients involves incorporating the patient's wishes for survival versus quality of life, and palliative and hospice care should be integrated into care plans. More research is needed to determine optimal strategies for patient selection and medical decision making, with the ultimate goal of improving clinical and patient centered outcomes in patients with stage D heart failure.