Faculty Bibliography

BACKGROUND:Glucagon-like peptide-1 receptor agonists (GLP-1RAs) promote weight loss and improve heart failure-related symptoms, quality of life, and functional capacity in patients with obesity and heart failure with preserved ejection fraction (HFpEF). However, their clinical effectiveness in nonobese patients with diabetes and HFpEF is understudied. METHODS:The TriNetX research network was used to identify adult patients (≥18 years) with type 2 diabetes mellitus (T2DM), heart failure with preserved ejection fraction (left ventricular ejection fraction ≥45%), elevated brain natriuretic peptide (≥ 150 pg/mL) or N-terminal pro-B-type natriuretic peptide(≥ 450 pg/mL) and a body mass index (BMI) <30 kg/m2 on or before August 31, 2022. Patients were divided into two groups based on GLP-1RA use. After propensity score matching, Cox proportional hazard ratios (HRs) were used to compare outcomes over a 12-month follow-up period. RESULTS:The study included 84,990 patients (n= 42,495 per group, mean age 64 years, 49% females, 65% white). Patients on GLP-1RAs were associated with lower incidence of heart failure exacerbation events (HR 0.60, 95% CI 0.58-0.62, p<0.001) and all-cause emergency room visits or hospitalizations (HR, 0.67, 95% CI 0.66-0.69; P < .001) compared with those not on GLP-1RAs. Other outcomes, including acute myocardial infarction, atrial fibrillation, ischemic stroke, pulmonary hypertension, C-reactive protein ≥ 5 mg/L, acute kidney injury, and the need for renal replacement therapy, were also significantly less frequent in the GLP-1RA group. These associated benefits persisted even among patients on a sodium-glucose cotransporter-2 inhibitor (SGLT2i). CONCLUSION/CONCLUSIONS:GLP-1RA use is associated with improved cardiovascular outcomes in nonobese patients with T2DM and HFpEF and has an associated incremental benefit even among patients on SGLT2i.

BACKGROUND/UNASSIGNED:Guidelines recommend palliative care (PC) for patients with heart failure. However, little research has been performed assessing the effect of PC consultation in patients with heart failure with preserved ejection fraction (HFpEF). OBJECTIVES/UNASSIGNED:The purpose of this study was to investigate the impact of PC consultation on symptom burden and health care utilization among individuals with HFpEF during the last 3 years of their lives. METHODS/UNASSIGNED:We retrospectively analyzed electronic medical records from 72 centers, mainly in the United States. All patients with HFpEF, identified using International Classification of Diseases codes, who died within 3 years of the diagnosis were selected and then stratified based on receipt of PC consultation. Propensity score matching was used to control for between-group differences. RESULTS/UNASSIGNED:Two hundred twenty-six thousand nine hundred twenty-one patients with HFpEF died within 3 years, only 26.4% of whom received a PC consult. In the unmatched cohort, patients who received a PC consult were more likely to be female, Black, and had more comorbidities. After propensity matching, patients receiving PC consultation were less likely to experience an emergency room visit or hospitalization (2.2% vs 4.6%), surgery or anesthesia (1.1% vs 4.2%), critical care (0.7% vs 1.9%), or receive cardiovascular procedures or tests (1.7% vs 4.7%). Furthermore, they were also less likely to have cardiorespiratory symptoms (2.5% vs 5.7%), heart failure exacerbations (1.6% vs 3.3%), cognitive symptoms (1.7% vs 3.4%), falls (0.3% vs 0.6%), and depression or anxiety (1.3% vs 2.8%). CONCLUSIONS/UNASSIGNED:PC consultation is associated with reduced potential unwanted health care utilization and improvement in symptoms in patients with HFpEF in their last 3 years of life. However, PC continues to be underused in this population.

Patients with pre-existing cardiovascular disease and risk factors are more likely to experience adverse outcomes associated with the novel coronavirus disease-2019 (COVID-19). Additionally, consistent reports of cardiac injury and de novo cardiac complications, including possible myocarditis, arrhythmia, and heart failure in patients without prior cardiovascular disease or significant risk factors, are emerging, possibly due to an accentuated host immune response and cytokine release syndrome. As the spread of the virus increases exponentially, many patients will require medical care either for COVID-19 related or traditional cardiovascular issues. While the COVID-19 pandemic is dominating the attention of the healthcare system, there is an unmet need for a standardized approach to deal with COVID-19 associated and other traditional cardiovascular issues during this period. We provide consensus guidance for the management of various cardiovascular conditions during the ongoing COVID-19 pandemic with the goal of providing the best care to all patients and minimizing the risk of exposure to frontline healthcare workers.

BACKGROUND:. We evaluated the off-label use of dexrazoxane as a cardioprotectant in adult patients with preexisting cardiomyopathy, undergoing anthracycline chemotherapy. METHODS:Between July 2015 and June 2017, five consecutive patients, with preexisting, asymptomatic, systolic left ventricular (LV) dysfunction who required anthracycline-based chemotherapy, were concomitantly treated with off-label dexrazoxane, administered 30 min before each anthracycline dose, regardless of cancer type or stage. Demographic, cardiovascular, and cancer-related outcomes were compared to those of three consecutive patients with asymptomatic cardiomyopathy treated earlier at the same hospital without dexrazoxane. RESULTS:). Anthracycline therapy resulted in a marked reduction in LVEF from 42.5% at baseline to 18%. All three developed symptomatic heart failure requiring hospitalization and intravenous diuretic therapy. Two of them died from cardiogenic shock and multi-organ failure. CONCLUSION/CONCLUSIONS:The concomitant administration of dexrazoxane in patients with preexisting cardiomyopathy permitted successful delivery of anthracycline-based chemotherapy without cardiac decompensation. Larger prospective trials are warranted to examine the use of dexrazoxane as a cardioprotectant in patients with preexisting cardiomyopathy who require anthracyclines.

Ibrutinib, a novel and potent Bruton tyrosine kinase inhibitor, is an effective and well-tolerated treatment for a variety of B-cell lymphomas. However, its use is associated with an increased incidence of atrial fibrillation (AF), ranging from 4% to 16%. We reviewed the original clinical trials that led to the approval of ibrutinib, as well as several other prospective and retrospective studies, to better appreciate the incidence of ibrutinib-associated AF. Based on 16 studies included in our analysis, the incidence of ibrutinib-associated AF was 5.77 per 100 person-years, which is much higher than rates previously reported with ibrutinib and compared with the general adult population. New onset AF in cancer patients is associated with a significantly higher risk of heart failure and thromboembolism, even after adjusting for known risk factors. In addition, ibrutinib poses unique challenges due to its interactions with many medications that are commonly used to manage AF. Ibrutinib also inhibits platelet activation and decisions regarding anticoagulation have to be carefully weighed against this increased risk of bleeding. Ibrutinib's interaction with calcium channel blockers, digoxin, amiodarone, and direct oral anticoagulants can result in either ibrutinib or other drug-related toxicity and careful selection and dose adjustment may be needed. Ibrutinib-associated AF can be a therapy-limiting side effect and physicians should be familiar with the special management considerations imposed by this agent. We review the potential mechanisms and incidence of ibrutinib-associated AF and propose an algorithm for its management.

Certain chemotherapeutic agents and mediastinal irradiation can be cardiotoxic and place cancer survivors at risk for developing advanced heart failure (HF). Anthracyclines are the prototypical agents associated with left ventricular (LV) dysfunction. Newer agents including trastuzumab and certain tyrosine kinase inhibitors such as sunitinib can also cause cardiomyopathy. Cancer survivors with advanced HF refractory to standard medical management should be considered for advanced therapies, including mechanical circulatory support (MCS) and transplantation. While overall outcomes after MCS and transplantation are similar in cancer survivors compared to other etiologies of HF, patients with radiation-induced restrictive cardiomyopathy have a significantly worse prognosis after transplantation. The increased need for right ventricular (RV) support after MCS in cancer survivors necessitates a careful evaluation for pre-operative RV dysfunction. Special consideration must also be given to the risk for recurrent malignancy, neurocognitive dysfunction, and increased psychological needs in this patient population.

Rapid and ultrarapid opioid detoxification (ROD and UROD) centers promise quick, painless, same-day detoxification treatment for patients with opioid addiction. The goal of ROD and UROD is to provide a rapid transition from opioid dependency to oral naltrexone therapy. The patient is given general anesthesia and high-dose opioid antagonists. This induces a severe withdrawal but spares the patient the experience. In theory, the process is complete within four to five hours. The patient awakens without opioid dependency and is started on oral naltrexone. Any subsequent, persistent withdrawal symptoms are treated symptomatically. A novel, unapproved approach is to compound a pellet of naltrexone and implant it in the subcutaneous tissue. In theory, this should result in continuous therapeutic levels for this drug, and avoid issues with noncompliance. CASE SERIES: This article reports six cases of complications from the same detoxification center that performed UROD with naltrexone pellet implantation, including pulmonary edema, prolonged withdrawal, drug toxicity, withdrawal from cross-addiction to alcohol and benzodiazepines, variceal rupture, aspiration pneumonia, and death. CONCLUSIONS: The risks of this procedure are great and further studies should assess its safety and the novel use of naltrexone