Baylor Heart and Vascular Institute

Roberts, W. C., V. S. Won, A. Vasudevan and J. M. Guileyardo (2016). “Causes of death and heart weights in adults at necropsy in a tertiary texas hospital, 2013-2015.” Am J Cardiol 118(11): 1758-1768.

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The causes of death and heart weights at death appear to be quite different in the USA today than in the first few decades of the last century. We determined the causes of death and heart weights at necropsy in 231 adults and compared the heart weights to those reported in several studies in the first half of the 20th century. Of the 231 patients, 91 (39%) died of a cardiovascular (CV) condition, and 140 (61%), of a non-CV condition. Of the 91 fatal CV disease cases, 48 had fatal coronary artery disease (CAD); of the remaining 183 cases without fatal CAD, 25 had narrowing >75% of 1 or more major epicardial coronary arteries. Thus, 73 of the 231 (32%) patients at necropsy had severe CAD. Comparison between the fatal CV and fatal non-CV cases disclosed variable age (mean 64 years vs mean 57 years) and heart weight (529 g vs 449 g) to be significantly different. Heart weight was found to be the only significantly variable between men and women. Comparison of the heart weights in this study to those recorded as “normal” hearts 75 to 115 years earlier showed that today’s “average” heart is much larger than those reported earlier. In contrast to the earlier studies, heart weight presently appears to increase with age and with an increase in body mass index. In conclusion, early studies in heart weight did not take into account today’s longer survival and therefore a high prevalence of systemic hypertension, diabetes mellitus, obesity (and cardiac adiposity), and the presence of atherosclerotic CAD. Additionally, the cause of death (CV vs non-CV) was rarely considered in the early studies of heart weight.

Joseph, S. M. (2016). “Lvads and contemplations on a flood.” J Card Fail: 2016 Dec [Epub ahead of print].

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Physicist Max Planck wrote that “the new scientific truth does not triumph by convincing its opponents and making them see the light, but rather because its opponents eventually die, and a new generation grows up that is familiar with it.”1 We are living in a very exciting time in cardiovascular medicine and especially in heart failure. It’s remarkable to think of how far we’ve come in such a short a period of time in our understanding of the physiology and application of durable continuous-flow ventricular assist devices. Even compared to 10 years ago, there has been a cultural change, albeit gradual, regarding the ways by which mechanical assist options are perceived. Therapies like extracorporeal life support (ECMO) and other percutaneous assist devices were commonly thought of as salvage therapy with a dismal prognosis, a heroic “hail Mary” last-ditch effort when all else failed. Now, these therapies are starting to be employed more widely and practitioners are becoming more acclimated to the complexities and nuances of managing a patient with non-physiologic circulation. Is it because scientific truth has converted the opponents? Or is it because, as our Editor-in-Chief Paul Hauptman suggested before, that HF as a specialty is “hot right now…”2, attracting a generation of HF doctors who were trained in the context of the rapid-growth phase of utilization of these devices, making it culturally part of their [our] fabric?

Zile, M. R., B. L. Claggett, M. F. Prescott, J. J. McMurray, M. Packer, J. L. Rouleau, K. Swedberg, A. S. Desai, J. Gong, V. C. Shi and S. D. Solomon (2016). “Prognostic implications of changes in n-terminal pro-b-type natriuretic peptide in patients with heart failure.” J Am Coll Cardiol 68(22): 2425-2436.

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BACKGROUND: Natriuretic peptides (NP) have prognostic value in heart failure (HF), although the clinical importance of changes in NP from baseline is unclear. OBJECTIVES: The authors assessed whether a reduction in N-terminal pro-B-type NP (NT-proBNP) was associated with a decrease in HF hospitalization and cardiovascular mortality (primary endpoint) in patients with HF and reduced ejection fraction, whether treatment with sacubitril/valsartan reduced NT-proBNP below specific partition values more than enalapril, and whether the relationship between changes in NT-proBNP and changes in the primary endpoint were dependent on assigned treatment. METHODS: In PARADIGM-HF (Prospective Comparison of ARNI [Angiotensin Receptor-Neprilysin Inhibitor] with ACEI [Angiotensin-Converting-Enzyme Inhibitor] to Determine Impact on Global Mortality and Morbidity in Heart Failure Trial), baseline NT-proBNP was measured in 2,080 patients; 1,292 had baseline values >1,000 pg/ml and were reassessed at 1 and 8 months. We related change in NT-proBNP to outcomes. RESULTS: One month after randomization, 24% of the baseline NT-proBNP levels 1,000 pg/ml had fallen to /=1,000 pg/ml. Risk of the primary endpoint was 59% lower in patients with a fall in NT-proBNP to /=1,000 pg/ml than in those without such a fall. In sacubitril/valsartan-treated patients, median NT-proBNP was significantly lower 1 month after randomization than in enalapril-treated patients, and it fell to =1,000 pg/ml in 31% versus 17% of patients treated with sacubitril/valsartan and enalapril, respectively. There was no significant interaction between treatment and the relationship between change in NT-proBNP and the subsequent risk of the primary endpoint. CONCLUSIONS: Patients who attained a significant reduction in NT-proBNP had a lower subsequent rate of cardiovascular death or HF hospitalization independent of the treatment group. Treatment with sacubitril/valsartan was nearly twice as likely as enalapril to reduce NT-proBNP to values /=1,000 pg/ml. (Prospective Comparison of ARNI [Angiotensin Receptor-Neprilysin Inhibitor] with ACEI [Angiotensin-Converting-Enzyme Inhibitor] to Determine Impact on Global Mortality and Morbidity in Heart Failure Trial)

Cedars, A. M. (2016). “In heart failure, where you have been may be more important than where you are: A role for patient-reported outcomes.” Am J Cardiol 26(1): 116-124.

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Current advanced care for patients with heart failure requires unique resources available only at a few large institutions. As a result, end-stage heart failure patients are often referred for care by teams who lack the insight of their regular primary cardiologist into their unique disease trajectory. This situation may result in clinical missteps. By tapping into a patient’s familiarity with their own trajectory through the use of patient-reported outcome metrics however, it is possible that this problem may be easily addressed.

Nadruz, W., Jr., B. L. Claggett, J. J. McMurray, M. Packer, M. R. Zile, J. L. Rouleau, A. S. Desai, K. Swedberg, M. Lefkowitz, V. C. Shi, M. F. Prescott and S. D. Solomon (2016). “Impact of body mass index on the accuracy of n-terminal pro-brain natriuretic peptide and brain natriuretic peptide for predicting outcomes in patients with chronic heart failure and reduced ejection fraction: Insights from the paradigm-hf study (prospective comparison of arni with acei to determine impact on global mortality and morbidity in heart failure trial).” Circulation 134(22): 1785-1787.

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The design and primary results of the PARADIGM-HF trial have been previously described.5 The patients randomized in the trial (n=8399) were required to have a plasma BNP ≥150 pg/mL or an NT-proBNP ≥600 pg/mL or, if they were hospitalized for HF within the previous 12 months, a BNP ≥100 pg/mL or an NT-proBNP ≥400 pg/ mL. The present study included patients with available BMI data and who had BNP and NT-proBNP locally measured at the time of screening (n=8217). It considered the primary outcome of the PARADIGM-HF trial, the composite of death from cardiovascular causes or a first hospitalization for HF, as the study outcome. The patients were categorized into 4 groups according to BMI: <25.0 (nonoverweight/obese; n=2536); 25.0 to 29.9 (overweight; n=3116); 30.0 to 34.9 (obese; n=1694); and ≥35.0 kg/m2 (moderately/severely obese; n=871). BNP and NT-proBNP were divided into quartiles within the whole studied population. The trial was approved by the ethics committee at each participating institution, and all the patients provided written informed consent.