Texas Heart Institute Journal Volume 41: Issue 3

Better outpatient management of heart failure might improve outcomes and reduce the number of rehospitalizations. This study describes recent outpatient heart-failure management in the United States.

We analyzed data from the National Ambulatory Medical Care Survey of 2006–2008, a multistage random sampling of non-Federal physician offices and hospital outpatient departments.

Annually, 1.7% of all outpatient visits were for heart failure (51% females and 77% non-Hispanic whites; mean age, 73 ± 0.5 yr). Typical comorbidities were hypertension (62%), hyperlipidemia (36%), diabetes mellitus (35%), and ischemic heart disease (29%). Body weight and blood pressure were recorded in about 80% of visits, and health education was given in about 40%. The percentage of patients taking β-blockers was 38%; the percentage taking angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (ACEI/ARBs) was 32%. Medication usage did not differ significantly by race or sex. In multivariate-adjusted logistic regression models, a visit to a cardiologist, hypertension, heart failure as a primary reason for the visit, and a visit duration longer than 15 minutes were positively associated with ACEI/ARB use; and a visit to a cardiologist, heart failure as a primary reason for the visit, the presence of ischemic heart disease, and visit duration longer than 15 minutes were positively associated with β-blocker use. Chronic obstructive pulmonary disease was negatively associated with β-blocker use. Approximately 1% of heart-failure visits resulted in hospitalization.

In outpatient heart-failure management, gaps that might warrant attention include suboptimal health education and low usage rates of medications, specifically ACEI/ARBs and β-blockers.

Left ventricular assist device (LVAD)-supported patients are evaluated routinely with use of transthoracic echocardiography. Values of left ventricular unloading in this unique patient population are needed to evaluate LVAD function and assist in patient follow-up.

We introduce a new M-mode measurement, the slope of the anterior mitral valve leaflet (SLAM), and compare its efficacy with that of other standard echocardiographically evaluated values for left ventricular loading, including E/e′ and pulmonary artery systolic pressures. Average SLAM values were determined retrospectively for cohorts of random, non-LVAD patients with moderately to severely impaired left ventricular ejection fraction (LVEF) (<0.35, n=60). In addition, pre- and post-LVAD implantation echocardiographic images of 81 patients were reviewed.

The average SLAM in patients with an LVEF <0.35 was 11.6 cm/s (95% confidence interval, 10.4–12.8); SLAM had a moderately strong correlation with E/e′ in these patients. Implantation of LVADs significantly increased the SLAM from 7.3 ± 2.44 to 14.7 ± 5.01 cm/s (n=42, P <0.0001). The LVAD-supported patients readmitted for exacerbation of congestive heart failure exhibited decreased SLAM from 12 ± 3.93 to 7.3 ± 3.5 cm/s (n=6, P=0.041). In addition, a cutpoint of 10 cm/s distinguished random patients with LVEF <0.35 from those in end-stage congestive heart failure (pre-LVAD) with an 88% sensitivity and a 55% specificity.

Evaluating ventricular unloading in LVAD patients remains challenging. Our novel M-mode value correlates with echocardiographic values of left ventricular filling in patients with moderate-to-severe systolic function and dynamically improves with the ventricular unloading of an LVAD.

Because the natural progression of low-gradient aortic stenosis (LGAS) has not been well defined, we performed a retrospective study of 116 consecutive patients with aortic stenosis who had undergone follow-up echocardiography at a median interval of 698 days (range, 371–1,020 d). All patients had preserved left ventricular ejection fraction (>0.50) during and after follow-up.

At baseline, patients were classified by aortic valve area (AVA) as having mild stenosis (≥1.5 cm²), moderate stenosis (≥1 to <1.5 cm²), or severe stenosis (<1 cm²). Severe aortic stenosis was further classified by mean gradient (LGAS, mean <40 mmHg; high-gradient aortic stenosis [HGAS], mean ≥40 mmHg). We compared baseline and follow-up values among 4 groups: patients with mild stenosis, moderate stenosis, LGAS, and HGAS.

At baseline, 30 patients had mild stenosis, 54 had moderate stenosis, 24 had LGAS, and 8 had HGAS. Compared with the moderate group, the LGAS group had lower AVA but similar mean gradient. Yet the actuarial curves for progressing to HGAS were significantly different: 25% of patients in LGAS reached HGAS status significantly earlier than did 25% of patients in the moderate-AS group (713 vs 881 d; P=0.035).

Because LGAS has a high propensity to progress to HGAS, we propose that low-gradient aortic stenosis patients be closely monitored as a distinct subgroup that warrants more frequent echocardiographic follow-up.

Smoking is the leading preventable cause of cancer, cardiovascular disease, pulmonary disease, and overall death in the United States. Unfortunately, some populations bear a disproportionate burden of tobacco-related morbidity and death. The most profound tobacco-related disparities are experienced by individuals with low socioeconomic status (SES) as indexed by factors such as education, income, and occupational status.¹ Furthermore, over the last several decades, SES disparities in tobacco use have more than doubled. The association between SES and tobacco-related disparities is explained in part by the fact that economically disadvantaged individuals have lower cessation rates.

Conceptual models describing the individual,

A 42-year-old, otherwise healthy man with exposure to domesticated buffalo presented with a 3-day history of intermittent headaches and word-finding difficulties. Magnetic resonance images (MRI) revealed an ischemic infarct in the left temporal lobe. A high-pitched, intense, pandiastolic murmur was detected at the right upper sternal border. A transthoracic echocardiogram showed moderate-to-severe aortic insufficiency. A transesophageal echocardiogram (TEE) showed a bicuspid aortic valve with possible leaflet perforation. Cardiac magnetic resonance (CMR) images confirmed regurgitation through a perforated bicuspid leaflet, excluded an abscess, and revealed a dilated ascending thoracic aorta (Fig. 1). The eccentric regurgitant jet and asymmetric aortic

Born to Observe

Editorial Commentary

Waiting

Outpatient Management of Heart Failure in the United States, 2006–2008

Slope of the Anterior Mitral Valve Leaflet: A New Measurement of Left Ventricular Unloading for Left Ventricular Assist Devices and Systolic Dysfunction

Natural Progression of Low-Gradient Severe Aortic Stenosis with Preserved Ejection Fraction

Role of Isoproterenol in Predicting the Success of Catheter Ablation in Patients with Reproducibly Inducible Atrioventricular Nodal Reentrant Tachycardia

Sex-Specific Biatrial Volumetric Measurements Obtained with Use of Multidetector Computed Tomography in Subjects with and without Coronary Artery Disease

Fourth Annual Symposium on Risk, Diagnosis and Treatment of Cardiovascular Disease in Women: ★ CME Information

Needs Statement

Spontaneous Coronary Artery Dissection (SCAD): New Insights into This Not-So-Rare Condition

Takotsubo Cardiomyopathy

What Is New in the 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Risk in Adults?

Patent Foramen Ovale

Socioeconomic Status and Smoking Cessation: Neighborhood Context as an Underlying Mechanism

★ CME Assessment Questions

Transventricular Mitral Valve Repair in Patients with Acute Forms of Ischemic Mitral Regurgitation

Exertional Dyspnea as a Symptom of Infrarenal Aortic Occlusive Disease

Cardiac Sarcoidosis Presenting as Constrictive Pericarditis

Intracardiac Abscess with Cutaneous Fistula Secondary to Ventricular Septal Defect Repair Simulating Sternal Wound Infection

Aortic Perforation by Active-Fixation Atrial Pacing Lead: An Unusual but Serious Complication

Cardioverter-Defibrillator Implantation to Treat Cardiac Fibroma-Induced Ventricular Tachycardia in a 70-Year-Old Woman

Asymptomatic Young Man with Danon Disease

Acute Anterior ST-Elevation Myocardial Infarction and Electrical Storm Secondary to Nondominant Right Coronary Artery Occlusion

Multidetector Computed Tomographic Imaging of Erdheim-Chester Disease

Frozen Elephant Trunk Repair for Descending Thoracic Aortic Dissection in a Man with a Hostile Left Pleural Cavity

Isolated Spontaneous Celiac Artery Dissection in a 47-Year-Old Man with von Willebrand Disease

Left Ventricular “Pseudo-Pseudoaneurysm”: An Unusual Case of Focal Left Ventricular Noncompaction

Cardiovascular Magnetic Resonance Depiction of Quadricuspid Pulmonary Valve with Associated Pulmonary Regurgitation and Pulmonary Artery Aneurysm

Comprehensive Evaluation of Culture-Negative Endocarditis with Use of Cardiac and 4-Dimensional-Flow Magnetic Resonance Imaging

Cor Triatriatum Sinister: Histopathologic Remarks

George J. Reul, MD: A Tribute

Accidental Left Ventricular Placement of a Leadless Micra Pacemaker Through a Patent Foramen Ovale

Impact of a Cardiology-Based Shock Team on Institutional Venoarterial Extracorporeal Membrane Oxygenation Use for Cardiogenic Shock

Double Atrial Septum With Interatrial Space in Patients Experiencing Ischemic Attack

Rhabdomyosarcoma Involving the Left Atrium and the Mitral Valve