There is high-quality evidence demonstrating that early initiation of statin use following an acute coronary syndrome (ACS) and persistent use thereafter reduces the risk of major adverse cardiovascular events (MACE) including mortality. However, despite the overwhelming evidence, adherence remains suboptimal and the medications frequently discontinued.1 Here we discuss the data on lipid-lowering therapy among patients with cardiovascular disease and discuss some potential interventions that address the gap. Among those with established atherosclerotic cardiovascular disease (ASCVD), poor statin adherence has been reported to be 47.2% in real-world registry data.2 Discontinuation rates have been reported ranging from 14%3 to 26.5%4 at 12 months in both large multicentre randomised clinical trial (RCT) data and national registries, with long-term discontinuation being 51% after 7 years in a large-scale RCT involving 39 countries.3 In a systematic review including 28 studies (5 nested case–control and 22 cohort studies), adherence to statin use in patients at high risk of ASCVD and those with established ASCVD was associated with a reduction in subsequent cardiovascular events (OR 1.22–5.26) and improved survival (OR 1.79–5.00).5 The US National Cardiovascular data Registry’s PINNACLE database (data collected at the point of care at cardiology practices) was used in a large study that showed that in 1 029 633 adults with known ASCVD, 27.9% did not receive any lipid-lowering medication.6 Similarly, other registries demonstrate high proportions of patients not receiving lipid-lowering therapy within the first year following an ACS in Australia7 and New Zealand8—22% and 25% respectively. Prescription of statins at the time of discharge after ACS is associated with continued use,7 and a range of data demonstrates significant gaps in use of lipid-lowering drugs among patients with cardiovascular disease. In the CONCORDANCE trial, failure to discharge patients on guideline-recommended therapies was 10 …
Digoxin is often used in the management of patients with heart failure (HF) with or without atrial fibrillation (AF). There is sound biological rationale for the use of digoxin, but the data on clinical outcomes with digoxin use in this patient population are conflicting. There is a single adequately powered randomised trial of digoxin in patients with HF in sinus rhythm.1 This trial showed a small but significant reduction in the rate of hospitalisation due to HF with the use of digoxin, when compared to placebo, among patients treated with ACE inhibitors and diuretics. There was no effect on mortality.1 On the contrary, there are numerous secondary analyses of observational data from randomised trials which suggest that there may be an increased risk of death from using digoxin, both in patients with HF, those in AF, or both.2 However, observational data on digoxin use suffer from treatment bias (confounding by indication), as the sickest patients are the ones who are prescribed digoxin. Propensity matched analyses have been attempted to overcome the effect of this bias with conflicting results.2 3 However, it is likely that because the magnitude of this bias is large, no amount of statistical adjustment can yield reliable effect estimates. This highlights the need for large, randomised trials of digoxin.3 References Digitalis Investigation G. The effect of digoxin on mortality and morbidity in patients with heart failure. N Engl J Med 1997;336:525–533. Ziff OJ, Lane DA, Samra M, Griffith M, Kirchhof P, Lip GY, Steeds RP, Townend J, Kotecha D. Safety and efficacy of digoxin: systematic review and meta-analysis of observational and controlled trial data. BMJ 2015;351:h4451. Karthikeyan G, Devasenapathy N, Zühlke L, Engel ME, Rangarajan S, Teo KK, Mayosi BM, Yusuf S; Global Rheumatic Heart Disease Registry (REMEDY) Investigators. Digoxin and clinical outcomes in the Global Rheumatic Heart Disease Registry. Heart 2018 Sep 12. pii: heartjnl-2018-313614.
Left ventricular assist device (LVAD) has been used for end-stage heart failure both as bridge to transplantation (BTT) and destination therapy (DT) for patients not suitable for heart transplantation. Stroke is a major cause of morbidity and mortality associated with LVAD therapy. We aimed to review the incidence and outcome of stroke during LVAD therapy in Hong Kong. Patients who had LVAD implantation from August 2010 to August 2018 for end-stage heart failure were reviewed. A total of 65 patients had LVAD implanted for end-stage heart failure (57 as BTT, 87.7%). The majority were male (n=55, 84.6%), with mean age of 49 years. Overall survival rates were 86.2% at 6 months and 79.2% at 12 months. There were 43 HeartMate IITM, 14 HeartWareTM HVADTM and 8 HeartMate 3TM implants. Twenty neurological events occurred in 18 patients with 10 cases of disabling stroke throughout the whole study period. There were 11 haemorrhagic strokes, 7 ischaemic strokes and 2 transient ischaemic attacks. Stroke and disabling stroke rates at 6 months were 20.7% and 12.1%, respectively. Disabling strokes were more common when haemorrhagic in origin (7 out of 10) and were the commonest cause of mortality in 9 out of 15 (60%) patients throughout the study period. In conclusion, stroke remains an important cause of morbidity and mortality among Hong Kong patients receiving LVAD therapy.
Objectives This meta-analysis and systematic review seeks to compare both characteristic parameters and procedural outcomes of atrial fibrillation (AF) catheter ablation in patients under general anaesthesia (GA)/deep sedation and mild/moderate sedation. Background Catheter ablation has become a widely applied intervention for treating symptomatic AF and arrhythmias that are refractory to medical therapy. It can be conducted through from mild sedation to GA. Methods PubMed and Embase were searched up to July 2018 for randomised controlled trials, cohort and observational studies that assessed the outcomes of catheter ablation under GA/deep sedation or mild/moderate sedation. Nine studies were included in this meta-analysis after screening with the inclusion and exclusion criteria. Heterogeneity between studies and publication bias was evaluated by I2 index and Egger’s regression, respectively. Results Our meta-analysis found catheter AF ablation with GA/deep sedation to be associated with reduced risk of recurrence (RR: 0.79, 95% CI 0.56 to 1.13, p=0.20) and complications (RR: 0.95, 95% CI 0.64 to 1.42, p=0.82), though statistically insignificant. In terms of procedural parameters, there was no significant difference between the two groups for both procedural time (SMD: −0.13, 95% CI −0.90 to 0.63, p=0.74) and fluoroscopy time (SMD: −0.41, 95% CI −1.40 to 0.58, p=0.41). Univariate meta-regression did not reveal any covariates as a moderating factor for complication and recurrence risk. Conclusion Apart from an increased likelihood of procedural success, ablation by GA/deep sedation was found to be non-significantly different from the mild/moderate sedation approach in both procedural parameters and outcome measures.
Background The importance of registries for collaborative quality improvement has been overlooked in low/middle-income countries (LMIC). Aga Khan University Hospital (AKUH) in Pakistan joined the Congenital Cardiac Catheterization Project on Outcomes-Quality Improvement (C3PO-QI) in March 2017 with the goal of leveraging international collaboration to improve patient care and institutional standards. Methods The C3PO-QI key driver-based approach was used, with certain modifications, for process re-engineering in AKUH’s congenital cardiac catheterisation laboratory (CCL) to reduce radiation exposure during cardiac catheterisation procedures (the primary outcome of C3PO- QI). Educating staff and standardising procedural documentation were the principal goals of the process re-engineering. Data survey was used to assess staff knowledge, attitude and practice before and after the initiative. Additionally, case demographics and outcomes were compared between AKUH and C3PO-QI centres. Results There was an increase in appropriate recording of radiation surrogates (0%–100%, p=0.00) and in the percentage of cases that met the established benchmark of ‘Ideal documentation’ (35% vs 95%, p=0.001). There was also an increase in self-reported staff interest during the case (25% vs 75%, p=0.001). AKUH versus C3PO-QI data showed similar demographic characteristics. There was a slight over-representation of diagnostic cases (42% vs 32%) as compared with interventional (58% vs 68%) at AKUH. Furthermore, interventional procedures were predominately PDA and ASD device closures (n=19 and 15, respectively). The frequency of adverse events were the same between AKUH and collaborative sites. Conclusion Collaborative efforts between developed and LMIC CCL are significant in advancing system-level processes.
Background Evidence and treatment guidelines support the use of statins in patients with established atherosclerotic cardiovascular disease (ASCVD) for secondary prevention of subsequent cardiovascular (CV) event. However, treatment adherence and persistence are still a concern. Methods We constructed a retrospective population-based cohort of patients, who initiated statin treatment within 90 days after discharge from hospital for ASCVD using the claims database of Taiwan National Health Insurance. Proportion of days covered (PDC) was used to measure statin adherence, and PDC ≥80% was defined as good adherence. The study outcomes were subsequent rehospitalisation or in-hospital death due to composite ASCVD, myocardial infarction or ischaemic stroke. Their associations with statin prescription adherence or persistence were analysed using time-dependent Cox proportional hazards model. Results The study cohort included 185 252 postdischarge statin initiators. There were 50 015 subsequent ASCVD rehospitalisations including 2858 in-hospital death during 7 years of study period. Good adherence was significantly associated with lower risk of ASCVD rehospitalisation (adjusted HR (aHR) 0.90; 95% CI 0.87 to 0.92) and significantly lower risk of in-hospital death (aHR 0.59; 95% CI 0.53 to 0.65). Compared with constant use of statin, patients in the three less persistent states (recent stop, non-persistence and intermittent use) were associated with higher risk of subsequent ASCVD rehospitalisation, aHRs were 1.16, 1.13 and 1.26, respectively (all p<0.05). The increased risks were consistent with specific outcome of acute myocardial infarction and ischaemic stroke. Also, patients in the recent stop period had significantly higher risk for fatal CV event. Conclusions Good adherence and persistence to statin therapy are significantly associated with lower risk of secondary ASCVD rehospitalisation and in-hospital death.
Heart failure with reduced left ventricular ejection fraction (HFrEF) is a frequently encountered clinical scenario. Coronary angiography (CAG) is usually performed to assess obstructive epicardial coronary artery disease (CAD) and the resultant ischaemia as causes of HFrEF. Objectives To determine the frequency of obstructive CAD (OCAD) in patients with HFrEF and its independent predictors and outcomes. Methods Retrospective observational study in Tabba Heart Institute on patients who underwent CAG during the past 4 years. Patients with prior known CAD or revascularisation were excluded. OCAD was defined as per the criteria from Felker et al. Regression modelling was performed to evaluate the predictors of OCAD. Survival was compared between the groups using the log rank test. Results Out of 2235 patients who underwent CAG, 260 had HFrEF as a primary indication for CAG and, of these, 119 (45.8%) had OCAD. Major predictors of OCAD were age >50 years at presentation (OR 2.0, 95% CI 1.1 to 3.7), presence of chest pain (OR 4.3, 95% CI 2.3 to 8.1), family history of premature CAD (OR 2.8, 95% CI 1.3 to 5.9) and utilisation of non-invasive (NIV) stress testing before CAG (OR 3.6, 95% CI 1.8 to 7.1). Survival was significantly lower (log rank p<0.001) in patients with OCAD with no revascularisation compared with OCAD with revascularisation or those who had non-obstructive CAD, and the latter two groups had comparable survival. Conclusions OCAD is detected in nearly half of the patients with reduced left ventricular systolic function undergoing CAG. Clinical judgement based on thorough history and use of NIV stress testing can help in appropriate patient selection for this test.
The global burden of heart failure has continued to increase dramatically with 26 million people affected and an estimated health expenditure of $31 billion worldwide. Several practice-influencing studies were reported recently, bringing advances along many frontiers in heart failure, particularly heart failure with reduced ejection fraction. In this article, we discuss nine distinct therapeutic areas that were significantly influenced by this scientific progress. These distinct areas include the emergence of sodium-glucose cotransporter-2 inhibitors, broadening the application of angiotensin-neprilysin inhibition, clinical considerations in therapy withdrawal in those patients with heart failure that 'recover' myocardial function, benefits of low-dose direct oral anticoagulants in sinus rhythm, targeted therapy for treating cardiac amyloidosis, usefulness of mitral valve repair in heart failure, the advent of newer left ventricular assist devices for advanced heart failure, the role of ablation in atrial fibrillation in heart failure, and finally the use of wearable defibrillators to address sudden death.
Background The benefit of an early coronary intervention after streptokinase (SK) therapy in low to intermediate-risk patients with ST-elevation myocardial infarction (STEMI) still remains uncertain. The current study aimed to evaluate the cardiovascular outcomes of early versus delayed coronary intervention in low to intermediate-risk patients with STEMI after successful therapy with SK. Methods We randomly assigned low to intermediate Global Registry of Acute Coronary Events risk score to patients with STEMI who had successful treatment with full-dose SK at Lampang Hospital and Maharaj Nakorn Chiang Mai Hospital into early and delayed coronary intervention groups. The primary endpoints were 30-day and 6-month composite cardiovascular outcomes (death, rehospitalised with acute coronary syndrome, rehospitalised with heart failure and stroke). Results One hundred and sixty-two patients were included in our study. At the 30 days, composite cardiovascular outcomes were 4.9% in the early coronary intervention group and 2.5% in the delayed group (p=0.682). At the 6 months, the composite cardiovascular outcomes were 16.1% in the early group and 6.2% in the delayed group (p=0.054). Conclusions The delayed coronary intervention (>24 hours) in low to intermediate STEMI after successful therapy with SK did not increase in short and long-term cardiovascular events compared with an early coronary intervention. Trial registration number NCT02131103.
The advent of left ventricular assist systems to support patients with advanced-stage heart failure has been a 50 year odyssey, now available broadly to such patients.1 Engineering advances have ushered in an era of small, durable devices that can be fully implanted within the chest. Yet, haemocompatibility related adverse events, which emanate from the interaction between the device and the patient they support are manifest principally in increased stroke rates, de novo device thrombosis requiring replacement and in gastrointestinal bleeding (a peculiar adverse event resulting from the unnatural physiology of continuous flow with low systemic pulse pressure).2 A novel fully „magnetically levitated pump, the HeartMate 3 pump has now been introduced which is engineered with wide blood flow pathways (to decrease shear stress and haemolysis) and programmed with an artificial intrinsic pulse. A large study has demonstrated its superiority in ameliorating pump thrombosis, reducing stroke rates and improving medical resource use and cost of care when compared with other devices such as the HeartMate II pump with a mechanical bearing and axial flow pathway.3 However, much needs to be learned, especially within the Asia Pacific region. Questions of genetic diversity in response to anticoagulation targets, predilection towards haemocompatibility complications and outcomes within this distinct population remain less well understood. Estimates of patient need in this region suggest that over 50 000 eligible patients with advanced heart failure may qualify for such mechanical support but access, cost and regulatory barriers as well as the optimal medical management of these pumps remain poorly understood. In the Asia Pacific realm, >100 centres currently implant such pumps with most performing <10 pumps annually and the top 20% of centres performing the majority of these surgical implants. Japan, Australia, India, Singapore and Taiwan lead the region in experience with durable implantable pumps. As experience ensues, there will be more widespread use and the field continues to await newer pumps that are not only forgiving on end points of adverse events but also forgettable by virtue of eliminating the need to be externally powered through a driveline that exits the body and connects to a power source.1 Myocardial recovery using haemodynamic support and facilitation of intensified pharmacotherapy is being studied in an effort to improve outcomes and restore patients to a better stage of less severe symptoms but this aspect remains poorly developed.4 The future is in smaller pumps that can provide partial support, mimic the physiological; flow pathways and maintain pulsatility. These devices will usher in earlier use and may provide the impetus to facilitate recovery in patients who are not too far advanced. References Mehra MR. Evolving disruption in left ventricular assist systems: Forgiving but not yet forgettable. Eur J Heart Fail 2018 December 3. doi:10.1002/ejhf.1340 [Epub ahead of print]. Mehra MR. The burden of haemocompatibility with left ventricular assist systems: A complex weave. Eur Heart J 2017 February 23. doi:10.1093/eurheartj/ehx036 Mehra MR, Goldstein DJ, Uriel N, et al. MOMENTUM 3 Investigators. Two-year outcomes with a magnetically levitated cardiac pump in heart failure. N Engl J Med 2018;378:1386–1395. Drakos SG, Mehra MR. Clinical myocardial recovery during long-term mechanical support in advanced heart failure: Insights into moving the field forward. J Heart Lung Transplant 2016;35:413–420.
Objective To investigate the effects of antithrombotic therapy on target lesion revascularisation (TLR) and major adverse cardiovascular and cerebrovascular events (MACCEs) at 12 months after femoropopliteal intervention with second-generation bare metal nitinol stents. Methods A total of 277 lesions in 258 limbs of 248 patients with de novo atherosclerosis in the above-the-knee femoropopliteal segment were analysed from the Japan multicentre postmarketing surveillance. Results At discharge, dual antiplatelet therapy (DAPT) was prescribed in 68.5% and cilostazol in 30.2% of patients. At 12 months of follow-up, prescriptions of DAPT significantly (p=0.0001) decreased to 51.2% and prescription of cilostazol remained unchanged (p=0.592) at 28.0%. Prescription of warfarin also remained unchanged (14.5% at discharge, 13.3% at 12 months, p=0.70). At 12 months, freedoms from TLR and MACCE were 89.4% and 89.7%, respectively. In a multivariate Cox proportional hazards model, neither DAPT nor cilostazol at discharge was associated with both TLR and MACCE at 12 months. However, warfarin at discharge was only independently associated with TLR at 12 months. Kaplan-Meier estimates demonstrated that warfarin at discharge yielded a significantly (p=0.013) lower freedom from TLR at 12 months than no warfarin at discharge. Freedom from TLR at 12 months by the Kaplan-Meier estimates was 77.8% (95% CI 59.0% to 88.8%) in patients with warfarin at discharge and 91.2% (95% CI 86.3% to 94.3%) in those without warfarin at discharge. Conclusions Clinical benefits of DAPT or cilostazol might be small in terms of TLR and MACCE at 12 months. Anticoagulation with warfarin at discharge might increase TLR at 12 months.
Objective ECG markers of heart failure (HF) with preserved ejection fraction (HFpEF) are lacking. We hypothesised that the Cornell product (CP) is a risk marker of HFpEF and has prognostic utility in HFpEF. Methods CP =[(amplitude of R wave in aVL+depth of S wave in V3)xQRS) was measured on baseline 12-lead ECG in a prospective Asian population-based study of 606 healthy controls (aged 55 +/- 10years, 45% men), 221 hypertensive controls (62 +/- 9 years, 58% men) and 242 HFpEF (68 +/- 12 years, 49% men); all with EF >= 50% and followed for 2 years for all-cause mortality and HF hospitalisations. Results CP increased across groups from healthy controls to hypertensive controls to HFpEF, and distinguished between HFpEF and hypertension with an optimal cut-off of >= 1800 mm*ms (sensitivity 40%, specificity 85%). Age, male sex, systolic blood pressure (SBP) and heart rate were independent predictors of CP >= 1800 mm*ms, and CP was associated with echocardiographic E/e' (r=0.27, p<0.01) and left ventricular mass index (r=0.46, p<0.01). Adjusting for clinical and echocardiographic variables and log N-terminal pro B-type natriuretic peptide (NT-proBNP), CP >= 1800 mm*ms was significantly associated with HFpEF (adjusted OR 2.7, 95% CI 1.0 to 7.0). At 2-year follow-up, there were 29 deaths and 61 HF hospitalisations, all within the HFpEF group. Even after adjusting for log NT-proBNP, clinical and echocardiographic variables, CP >= 1800 mm*ms remained strongly associated with a higher composite endpoint of all-cause mortality and HF hospitalisations (adjusted HR 2.1, 95% CI 1.2 to 3.5). Conclusion The Cornell product is an easily applicable ECG marker of HFpEF and predicts poor prognosis by reflecting the severity of diastolic dysfunction and LV hypertrophy.
Advanced cardiac diseases are common non-cancer conditions that require good palliative care. Palliative Care should embrace both cancer and non-cancer conditions, and is applicable early in the course of illness, in conjunction with other therapies. There is a high prevalence of symptoms and distress in heat failure (HF) necessitating palliative care, which include not just dyspnoea and oedema but also a range of other symptoms that are all sub-optimally controlled at the end of life.1 For patients with HF, palliative care attends to physical, psychological, social and spiritual distress, caring for both patients and families with optimisation of quality of life.2 Palliative care also facilitates communication and complex decision-making with advance care planning. Palliative support should be offered once there is a need. Prognostic indicators are also available in alerting clinicians to timing and need for palliative care, especially in older patients.3 Evidence for benefit of early palliative care is emerging for structured palliative care services for HF. The PAL-HF randomised controlled trial shows that an interdisciplinary palliative care can yield greater benefits in quality of life, anxiety, depression, and spiritual well-being compared with usual care alone.4 Challenges in withholding or withdrawing care options like with non-invasive ventilation, implantable defibrillators, left ventricular assistive devices will need to be further addressed. Serious illness conversation guide from Harvard University is available also in local Hong Kong Chinese setting to facilitate discussion.5 Good HF care necessitates an integrated care programme, with palliative team working hand in hand with cardiologists. References Gibbs LME, Addington-Hall J, Gibbs JSR. Dying from Heart Failure: lessons from Palliative Care. BMJ 1998;317:961–962. Braun LT, Grady KL, Kutner JS, et al. Palliative Care and Cardiovascular Disease and Stroke: A Policy Statement from the American Heart Association/American Stroke Association. Circulation 2016;134:e198–e225. Coventry PA, Grande GE, Richards TA, Todd CJ. Prediction of appropriate timing of palliative care for older adults with non –malignant life-threatening disease. A systematic review. Age Ageing 2005;34:218–27. Rogers JG, Patel CB, Mentz RJ, et al. Palliative Care in Heart Failure: The PAL-HF Randomised, Controlled Clinical Trial. J Am Coll Cardiol 2017;70:331–341. Jockey Club End-of-Life Community Care Project. Serious illness communication guide in Hong Kong, 2018. (accessible at https://youtu.be/_5RxXYHWCPg).
The perioperative management of patients with a left ventricular assist device (LVAD) presents a whole set of challenges to the nurses at the bedside and outpatient settings.1 Despite the remarkable advancements in technology, the care of patients following LVAD implant remains complex for the multidisciplinary healthcare team. This presentation provides a brief overview of the currently used durable LVAD designs worldwide. These include axial (HeartMate IITM) and magnetic flow levitation (HeartMate 3TM and HeartWare HVAD®) LVADs.2 Discussion of the nursing management of patients post-LVAD implant in the critical care, progressive care, and in the outpatient care settings will be approached at conceptual level. This approach will equip the participant with a ‘thinking framework’ guiding his/her actions in caring for LVAD patients. Salient nursing actions include early detection and management of post-surgical complications, device-related complications, heart failure symptom exacerbations, infection, among others. The nurse’s role in helping patients attain an optimum level of functioning post-implantation during hospitalisation and the impact of the nurse in supporting patients (and caregivers) to attain an increase in quality of life are highlighted. References Chmielinski A, Koons B. Nursing care for the patient with a left ventricular assist device. Nursing 2018. 2017;47:34–40. Montalto A, Loforte A, Musumeci F, Krabatsch T, Slaughter M (Eds.). Mechanical circulatory support in end-stage heart failure: a practical manual. Cham, Switzerland: Springer International Publishing; 2017. doi:10.1007/978-3-319-43383-7
The diagnosis and emergency management of patients with shock (poor end organ perfusion with reduced tissue oxygen delivery, usually associated with systolic hypotension) is difficult even in optimum circumstances. The challenge is multiplied when patients have to be managed in overcrowded and poorly resourced emergency departments (ED). In Hong Kong, public hospital EDs manage over two million patient attendances annually, equivalent to 30% of Hong Kong’s population. Around 30% of ED patients require emergency hospital admission, with the majority being more than 80 years old. Hong Kong’s ageing population, with its associated comorbidities and polypharmacy, has inevitably contributed to rising numbers of critically ill ED patients in recent years. Shock is a major cause (and consequence) of critical illness in ED patients. Hypovolaemic shock is frequently secondary to gastrointestinal bleeding and trauma; septic shock is increasingly common due to better recognition in the ED and more patients with chronic immunosuppression. Cardiogenic shock is common, usually due to acute myocardial infarction. Optimum treatment for these patients is undoubtedly emergency revascularisation by primary percutaneous coronary intervention (PCI). Hong Kong currently does not have a regionalised or coordinated PCI service and this may contribute to the poor outcomes seen in elderly patients with cardiogenic shock. Increasingly, patients with acute on chronic heart failure often present with shock and require a coordinated specialist approach at the earliest opportunity to improve outcomes. Comprehensive collaboration between emergency medicine physicians, cardiologists, cardiothoracic surgeons and critical care services and shared clinical management are vital to optimise patient outcomes.
Although left ventricular assist devices (LVADs) have revolutionised the treatment of advanced heart failure, LVAD infection (LVADI) remains a significant cause of morbidity and mortality in LVAD patients. The International Society of Heart and Lung Transplantation defines LVADI in three categories: VAD-specific infections (pump/cannula, pocket, driveline); VAD-related infections (infective endocarditis, blood stream infection, mediastinitis); and non-VAD infections.1 Infection should be excluded or appropriately treated by an infectious disease physician before LVAD implantation when clinically feasible. Surgical techniques such as increasing intrafascial tunnelling and externalisation of the silicone portion of the driveline may help reduce infections.2 Besides culture tests, additional imaging, such as ultrasonography or computed tomography may be warranted if underlying abscess is suspected.3 The recommended treatment includes antimicrobial therapy, local debridement of the exit sites; surgical drainage, driveline repositioning and instalment of a wound VAC (or vacuum-assisted closure) system in patients with deep infection,4 surgical debridement and device exchange in the setting of persistent or relapsing blood stream infection (BSI) despite adequate antimicrobial and surgical therapy; pump exchange should be performed if feasible, in patients with persistent sepsis and instability due to device infection while heart transplant should be considered in haemodynamically stable transplant candidates with BSI.1 The clinical manifestations and management of LVADI vary based on the type and extent of infection, and the causative pathogens. Understanding these differences is critical in making timely diagnoses and providing appropriate management interventions for LVADI. References Kusne S, Mooney M, Danziger-Isakov L, Kaan A, Lund LH, Lyster H, Wieselthaler G, Aslam S, Cagliostro B, Chen J, Combs P, Cochrane A, Conway J, Cowger J, Frigerio M, Gellatly R, Grossi P, Gustafsson F, Hannan M, Lorts A, Martin S, Pinney S, Silveira FP, Schubert S, Schueler S, Strueber M, Uriel N, Wrightson N, Zabner R, Huprikar S. An ISHLT consensus document for prevention and management strategies for mechanical circulatory support infection. J Heart Lung Transplant 2017;36:1137–1153. Trachtenberg BH, Cordero-Reyes A, Elias B, Loebe M. A review of infections in patients with left ventricular assist devices: prevention, diagnosis and management. Methodist Debakey Cardiovasc J 2015;11:28–32. Slaughter MS, Pagani FD, Rogers JG, Miller LW, Sun B, Russell SD, Starling RC, Chen L, Boyle AJ, Chillcott S, Adamson RM, Blood MS, Camacho MT, Idrissi KA, Petty M, Sobieski M, Wright S, Myers TJ, Farrar DJ; HeartMate II Clinical Investigators. Clinical management of continuous-flow left ventricular assist devices in advanced heart failure. J Heart Lung Transplant 2010;29(4 Suppl):S1–39. Yarboro LT, Bergin JD, Kennedy JL, Ballew CC, Benton EM, Ailawadi G, Kern JA. Technique for minimizing and treating driveline infections. Ann Cardiothorac Surg 2014;3:557–562.
Whilst there has recently been unprecedented growth in heart transplants (HTx) in North America, the number has been static or falling in most European countries. These have resulted in significant increases in the waiting times. In the UK, an Urgent Heart Allocation Scheme has been in existence since 2001. With a growing number of heart failure patients on temporary mechanical circulatory support (MCS) devices, a Super Urgent category was introduced in 2016. So far, ∼15% of HTx in the UK are performed under this new category and the median waiting time has been ≈7 days. Post-transplant 30 day survival has been reassuring. However, ongoing monitoring will be required to ensure effectiveness. The other major development has been donation after circulatory death (DCD) HTx. To date, ∼100 DCD HTx have been performed worldwide, with 70 of these being in the UK. Growing waiting lists have led to increased implantation of bridge-to-transplant left ventricular assist devices (LVAD). However, the extended waiting times for donor hearts in stable patients mean that patients being bridged are effectively having destination therapy by default. Whilst destination therapy is approved in some countries, the available evidence has not been accepted by other countries. The Swedish Evaluation of LVAD as Permanent Treatment in End-stage Heart Failure (SweVAD) is a prospective randomised study comparing LVAD therapy with optimal medical therapy. Recruitment commenced in 2016 with the aim of randomising 74 patients. Outcomes and adverse events associated with implantable MCS will further improve as new devices using novel pumping mechanisms with lower shear stress are in development to address inherent limitations of current devices.
Pulmonary arterial hypertension (PAH) is a complex and devastating disease. According to a longitudinal United States-based registry, connective tissue disease (CTD) accounted for more than 50% of all patients with PAH, in which systemic sclerosis comprised the largest CTD-related PAH.1 In contrast to Western countries, systemic lupus erythematosus (SLE) is a more common CTD than systemic sclerosis in the Asia-Pacific region.2 A cohort study from China has shown that SLE, instead of systemic sclerosis, comprised the largest proportion of all CTD-related PAH.3 The prevalence of PAH in SLE is estimated at 0.5%–17.5%.4 The pathogenesis of PAH involves multiple mechanisms including vasculitis, in situ thrombosis to interstitial lung disease which may all increase pulmonary vascular resistance and lead to right heart failure. The leading risk factors for the development of PAH in SLE patients include Raynaud’s phenomenon, anti-U1 RNP antibody and anti-cardiolipin antibodies positivity. Since PAH is potentially life-threatening, early detection is crucial to improve the outcomes of this condition. Currently, the diagnostic algorithm for PAH in SLE patients follows that of international guidelines. Diagnosis is confirmed by right heart catheterisation. Treatments are similar to the therapeutic interventions for patients with idiopathic PAH. Since inflammatory and dysregulated immune components may play a major role in the pathogenesis of PAH in SLE, glucocorticoids and immunosuppressive therapies including cyclophosphamide are used, although the immunosuppressive therapy trials were small, uncontrolled studies only. Regular follow-up with prognostic evaluation and risk assessment should be performed and the treatment should be individualised accordingly. References McGoon MD, Miller DP. REVEAL: a contemporary US pulmonary arterial hypertension registry. Eur Respir Rev 2012;21:8–18. Jakes RW, Bae SC, Louthrenoo W, Mok CC, Navarra SV, Kwon N. Systematic review of the epidemiology of systemic lupus erythematosus in the Asia-Pacific region: prevalence, incidence, clinical features, and mortality. Arthritis Care Res (Hoboken) 2012;64:159–168. Zhao J, Wang Q, Liu Y, Tian Z, Guo X, Wang H, Lai J, Huang C, Yang X, Li M, Zeng X. Clinical characteristics and survival of pulmonary arterial hypertension associated with three major connective tissue diseases: A cohort study in China. Int J Cardiol 2017;236:432–437. Condliffe R, Kiely DG, Peacock AJ, Corris PA, Gibbs JS, Vrapi F, Das C, Elliot CA, Johnson M, DeSoyza J, Torpy C, Goldsmith K, Hodgkins D, Hughes RJ, Pepke-Zaba J, Coghlan JG. Connective tissue disease-associated pulmonary arterial hypertension in the modern treatment era. Am J Respir Crit Care Med 2009;179:151–157.
Prior to establishment of the heart failure (HF) nurse clinic at Queen Elizabeth Hospital (QEH), Hong Kong in 2003, high rates of hospital readmission were seen in HF patients. Despite shortage of manpower and resources in the Hong Kong public healthcare sector, the clinic has over the years improved patient outcomes including functional capacity and rates of hospital readmission. Initially, cardiac nurses contributed to promoting patients’ health seeking behaviour through education. By 2012, the clinic provided protocol-guided titration of medications to achieve optimal dosing of medications. The HF clinic nurses would individually titrate and maximise medical therapy according to the pre-set protocol endorsed by cardiologists.1 HF patients were closely followed, particularly for those referred from Outpatient Clinics or recently discharged from hospital requiring medication adjustment and education. On average, HF patients were followed up every 2–4 weeks, and sometimes even weekly for close monitoring. In contrast, follow-up at Outpatient Clinics occurred at 3- to 4 month intervals. Apart from education and medication titration, cardiac nurses of the HF clinic also helped to identify and refer difficult-to-manage patients for advanced treatment such as device therapy. Nurses at the HF clinic have a high degree of autonomy, not only in titrating medication according to protocol but also in customising care plan for patients. The QEH HF nurse clinic has been successful in reducing HF patients’ length of hospital stay and readmission rates (figures 1 and 2), as well as in improving patients’ left ventricular ejection fraction, 6 min walk distance, quality of life, and compliance to diet and medications. References Hunt SA, Abraham WT, Chin MH, et al. ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2001 Guidelines for the Evaluation and Management of Heart Failure): developed in collaboration with the American College of Chest Physicians and the International Society for Heart and Lung Transplantation: endorsed by the Heart Rhythm Society. Circulation 2005;112:e154–235.
Intra-aortic balloon pump (IABP), which simultaneously augments coronary blood flow and decreases myocardial oxygen demand, usually provides haemodynamic support in patients with impaired left ventricular function undergoing percutaneous coronary intervention (PCI)1 2 or for patients with established cardiogenic shock.3 Several observational studies have reported that prophylactic IABP insertion could reduce major adverse cardiovascular events (MACE) compared with a provisional counterpulsation strategy during high-risk PCI.4 However, meta-analysis did not reveal a benefit of routine elective use of IABP or percutaneous ventricular assisted device.5 Due to a lack of national data from Taiwan, this presentation therefore summarises the experience at Taipei Veterans General Hospital, and the patients’ clinical characteristics and long-term outcomes including cardiac mortality and MACE associated with high-risk PCI and/or acute myocardial infarction. References Kern MJ, Aguirre F, Bach R, Donohue T, Siegel R, Segal J. Augmentation of coronary blood flow by intra-aortic balloon pumping in patients after coronary angioplasty. Circulation 1993;87:500–511. Cohen M, Urban P, Christenson JT, Joseph DL, Freedman RJ Jr, Miller MF, Ohman EM, Reddy RC, Stone GW, Ferguson JJ 3rd; Benchmark Registry Collaborators. Intra-aortic balloon counterpulsation in US and non-US centres: results of the Benchmark Registry. Eur Heart J 2003;24:1763–1770. Sjauw KD, Engstrom AE, Vis MM, van der Schaaf RJ, Baan J Jr, Koch KT, de Winter RJ, Piek JJ, Tijssen JG, Henriques JP. A systematic review and meta-analysis of intra-aortic balloon pump therapy in ST-elevation myocardial infarction: should we change the guidelines?Eur Heart J 2009;30:459–468. Mishra S, Chu WW, Torguson R, Wolfram R, Deible R, Suddath WO, Pichard AD, Satler LF, Kent KM, Waksman R. Role of prophylactic intra-aortic balloon pump in high-risk patients undergoing percutaneous coronary intervention. Am J Cardiol 2006;98:608–612. Lee JM, Park J, Kang J, Jeon KH, Jung JH, Lee SE, Han JK, Kim HL, Yang HM, Park KW, Kang HJ, Koo BK, Kim SH, Kim HS. The efficacy and safety of mechanical hemodynamic support in patients undergoing high-risk percutaneous coronary intervention with or without cardiogenic shock: Bayesian approach network meta-analysis of 13 randomized controlled trials. Int J Cardiol2015;184:36–46.
