Faculty Bibliography

Acute decompensated heart failure (ADHF) is a complex clinical event associated with excess morbidity and mortality. Managing ADHF patients is challenging because of the lack of effective treatments that both reduce symptoms and improve clinical outcomes. Existing guideline recommendations are largely based on expert opinion, but several recently published trials have yielded important data to inform both current clinical practice and future research directions. New insight has been gained regarding volume management, including dosing strategies for intravenous loop diuretics and the role of ultrafiltration in patients with heart failure and renal dysfunction. Although the largest ADHF trial to date (ASCEND-HF, using nesiritide) was neutral, promising results with other investigational agents have been reported. If these findings are confirmed in phase III trials, novel compounds, such as relaxin, omecamtiv mecarbil, and ularitide, among others, may become therapeutic options. Translation of research findings into quality clinical care can not be overemphasized. Although many gaps in knowledge exist, ongoing studies will address issues around delivery of evidence-based care to achieve the goal of improving the health status and clinical outcomes of patients with ADHF.

The clinical management of takotsubo cardiomyopathy is challenging. Its diagnosis must be made on clinical grounds and differentiated from alternative diagnoses with echocardiography, serum biomarkers, cardiac catheterization, and cardiac magnetic resonance imaging. Acute therapy includes supportive care, targeting the precipitating trigger if known, b-blockade, inhibitors of the renin-angiotensin system, and consideration of systemic anticoagulation in all patients. Recovery of left ventricular function to normal is expected regardless of early therapy. Although the prognosis is generally favorable, monitoring for early dangerous complications is essential. There is no evidence to support use of long-term medical therapy to reduce the risk of recurrence.

OBJECTIVE: We sought to characterize temporal trends in hospitalizations with heart failure as a primary or secondary diagnosis. BACKGROUND: Heart failure patients are frequently admitted for both heart failure and other causes. METHODS: Using the Nationwide Inpatient Sample (NIS), we evaluated trends in heart failure hospitalizations between 2001 and 2009. Hospitalizations were categorized as either primary or secondary heart failure hospitalizations based the location of heart failure in the discharge diagnosis. National estimates were calculated using the sampling weights of the NIS. Age- and gender-standardized hospitalization rates were determined by dividing the number of hospitalizations by the United States population in a given year and using direct standardization. RESULTS: The number of primary heart failure hospitalizations in the United States decreased from 1,137,944 in 2001 to 1,086,685 in 2009, while secondary heart failure hospitalizations increased from 2,753,793 to 3,158,179 over the same period. Age- and gender-adjusted rates of primary heart failure hospitalizations decreased steadily over 2001-2009, from 566 to 468 per 100,000 people. Rates of secondary heart failure hospitalizations initially increased, from 1370 to 1476 per 100,000 from 2001-2006, then decreased to 1359 per 100,000 in 2009. Common primary diagnoses for secondary heart failure hospitalizations included pulmonary disease, renal failure, and infections. CONCLUSIONS: Although primary heart failure hospitalizations declined, rates of hospitalizations with a secondary diagnosis of heart failure were stable in the past decade. Strategies to reduce the high burden of hospitalizations of heart failure patients should include consideration of both cardiac disease and non-cardiac conditions.

Background: Vasculature involvement of AL amyloid or amyloid fibrils has been commonly reported in tissue biopsy. However, the prognostic role of vasculature involvement has not been studied. Methods: Tissue biopsies of patients with biopsy-proven AL amyloidosis were reviewed between 2006 to 2011. Tissue and vasculature involvement were recorded from Congo red staining and/or electronic microscopic detection of amyloid fibrils in tissue and/or capillaries. Amyloid deposition in vasculature was defined as Congo red staining of small vessels and fibrils deposition in capillaries under electronic microscope. EKG and echocardiography at the time of diagnosis were reviewed. NCCN Guidelines Version 1.2012 was used for reassessing cardiac involvement for all patients. Death was censored till November 30, 2011. Results: 28 patients with biopsy data available were included for the analysis. Mean age was 64.8 +/- 9.9 years. All patients had at least one organ biopsy with tissue Congo Red staining positive. 18 patients with positive amyloid deposition in vasculature (V positive), 14 (77.8%) had cardiac involvement based on NCCN criteria; 10 patients with negative amyloid deposition (V negative), 4 (40%) had cardiac involvement (P<0.01). LV wall thickness and LV filling pressure (E/e') were significantly increased in V positive group comparing with V negative group (15 mm +/- 0.07 vs 1.1 mm +/- 0.07; 21.6 +/-1.7 vs 11 +/-1.7 respectively, both P = 0.002). 7 cases in V positive group had pericardial effusion comparing 0 case in V negative group (P = 0.03). 12 cases with low voltage from ECG in V positive group comparing with 3 cases in V negative group (P = 0.03). LV ejection fraction, left atrium size, pulmonary pressure, troponin I and NT-ProBNP levels were not significantly different between two groups. Mortality rate in V positive group (10/18, 55.6%) was significantly higher comparing with V negative group (2/10, 20%) (P = 0.04) Conclusions: The patients with positive amyloid deposition in vasculature !