Sreenivasan, Jayakumar

Various pharmacotherapies exist for heart failure with preserved ejection fraction (HFpEF), but with unclear comparative efficacy. We searched EMBASE, Medline, and Cochrane Library from inception through August 2021 for all randomized clinical trials in HFpEF (EF >40%) that evaluated beta-blockers, mineralocorticoid receptor antagonist (MRA), angiotensin-converting enzyme inhibitors (ACE), angiotensin receptor blockers (ARB), angiotensin receptor-neprilysin inhibitor (ARNI), and sodium-glucose cotransporter-2 inhibitors (SGLT2i). Outcomes assessed were cardiovascular mortality, all-cause mortality, and HF hospitalization. A frequentist network meta-analysis was performed with a random-effects model. We included 22 randomized clinical trials (30,673 participants; mean age = 71.7 ± 4.2 years; females = 49.3 ± 7.7%; median follow-up = 24.4 ± 11.1 months). Compared with placebo, there was no statistically significant difference in cardiovascular mortality [beta-blockers; odds ratio (OR) 0.79 (0.46–1.34), MRA; OR 0.90 (0.70–1.14), ACE OR 0.95 (0.59–1.53), ARB; OR 1.02 (0.87–1.19), ARNI; OR 0.97 (0.74–1.26) and SGLT2i; OR 1.00 (0.84–1.18)] or all-cause mortality [beta blockers; OR 0.75 (0.54–1.04), MRA; OR 0.90 (0.75–1.08) ACE; OR 1.05 (0.71–1.54), ARB; OR 1.03 (0.91–1.15), ARNI; OR 0.99 (0.82–1.20) and SGLT2i; OR 1.00 (0.89–1.13)]. The certainty in these estimates was low or very low. There was a significantly reduction in HF hospitalization with the use of SGLT2i [OR 0.71 (0.62–0.82), moderate certainty], ARNI [OR 0.77 (0.63–0.94), low certainty], and MRA [OR 0.81 (0.66–0.98), moderate certainty]; with corresponding P scores of 0.84, 0.68, and 0.58, respectively. In HFpEF, the use of beta-blockers, MRA, ACE/ARB/ARNI, or SGLT2i was not associated with improved cardiovascular or all-cause mortality. SGLT2i, ARNI, and MRA reduced the risk of HF hospitalizations.

Coronavirus disease 2019 (COVID-19) is characterized by a clinical spectrum of diseases ranging from asymptomatic or mild cases to severe pneumonia with acute respiratory distress syndrome (ARDS) requiring mechanical ventilation. Extracorporeal membrane oxygenation (ECMO) has been used as rescue therapy in appropriate patients with COVID-19 complicated by ARDS refractory to mechanical ventilation. In this study, we review the indications, challenges, complications, and clinical outcomes of ECMO utilization in critically ill patients with COVID-19-related ARDS. Most of these patients required venovenous ECMO. Although the risk of mortality and complications is very high among patients with COVID-19 requiring ECMO, it is similar to that of non-COVID-19 patients with ARDS requiring ECMO. ECMO is a resource-intensive therapy, with an inherent risk of complications, which makes its availability limited and its use challenging in the midst of a pandemic. Well-maintained data registries, with timely reporting of outcomes and evidence-based clinical guidelines, are necessary for the careful allocation of resources and for the development of standardized utilization protocols.

Introduction: Heart transplantation is associated with prolonged survival and improved quality of life in patients with advanced cardiac disease albeit with an increased risk of malignancies due to the use of immunosuppressant medications. Our study aimed to determine the types and trends of in patients’ hospitalization for malignancies among heart transplant patients. Methods: We queried the 2005 to 2014 National Inpatient Sample(NIS) database to identify all patients with a history of heart transplant (ICD-9 codes V412, 99683) who were hospitalized with a diagnosis of cancer. The main outcome was the trend in cancer admissions. Secondary outcome were inpatient mortality, total charge and length of stay. Cochran’s and Mantel-Haenszel test was used to assess trends of cancer admissions. Adjusted OR were used to compare the incidence of death between the two groups. Results: A total of 36543(weighted national estimate of 177,604) patients were admitted with a history of heart transplantation over the study period, out of which 2347(6.4%) had a diagnosis of a malignancy. Cancer patients were older (Mean age 66±12 Vs. 61.1±18 P-Value <0.001) and were more likely to be male. There was an increasing trend in the rate of cancer admissions over the study period from 60 per 1000 patients in 2005 to 70 per 1000patients in 2014(P-Vale <0.0001). Overall the most prevalent cancer was Non-Hodgkin’s 20.9% followed by lung Cancer 19.1%. ninety-seven patients(4.1%) had a 2 or more cancers. Patients with a diagnosis of cancer were more likely to die while inpatients as compared those without a diagnosis of cancer (6.6% vs. 3.1%, adjusted OR 2.42 95%CI 1.53-3.38 P-value <0.001). Lastly, patients with cancer had an increased total median coast and a longer length of stay(Total charge(39735 vs, 32,035, P value =<0.001 and 5 vs. 4. P-value <0.001). Conclusion: Development of cancer among patients with a history of transplant adds significant morbidity and mortality. Further studies are needed to determine effective ways to reduce morbidity in this patient cohort.

Introduction: Atrial fibrillation (AF) adversely affect the outcomes in the patients of heart failure (HF) with reduced ejection fraction, however there are limited data exploring such an association in HF with preserved ejection fraction (HFpEF). Hypothesis: AF is associated with worse outcomes in HFpEF. Methods: We included all the patients with the primary diagnosis of HFpEF from the national inpatient sample (NIS) database (2012-2014) using ICD-9 codes. Exposure of interest was AF. Primary outcome was in-hospital mortality and secondary outcomes were rates of sudden cardiac arrest (SCA), syncope, cardiogenic shock, embolic stroke, acute myocardial infarction (AMI), acute kidney injury (AKI), passive hepatic congestion, ventricular fibrillation (V fib) and flutter, ventricular assist device (VAD), AICD, cardiac resynchronization therapy (CRT), intra-aortic balloon placement (IABP) placement and heart transplantation. Hospitalization cost was also studied. Results: Our study cohorts included 26,51,970 patients of HFpEF with AF and 37,44,101 patients of HFpEF without AF. AF cohort had more numbers of older patients and less female representation. In-hospital mortality was more in AF cohort. Similarly, the odds of SCA, cardiogenic shock, embolic stroke, passive hepatic congestion, Vfib and flutter, AICD and CRT placement were higher in AF cohort. The odds of syncope, AMI and AKI were lower in AF cohort as compared to non-AF cohort. While the odds of heart transplantation and VAD and IABP use remained comparable between the study cohorts, AF cohort incurred greater of cost of hospitalization. Conclusion: AF in HFpEF patients is associated with increased in-hospital mortality and cardiogenic shock and should be aggressively treated for improved outcomes.