Publications by authors named "Kevin S Shah"

25 Publications

  • Page 1 of 1

SARS-CoV-2 as an inflammatory cardiovascular disease: current knowledge and future challenges.

Future Cardiol 2021 Mar 19. Epub 2021 Mar 19.

Nora Eccles Harrison Cardiovascular Research & Training Institute, University of Utah, Salt Lake City, UT 84112, USA.

SARS-CoV-2 is responsible for the 2020 global coronavirus disease 2019 (COVID-19) pandemic. In patients with COVID-19, multiple cardiovascular (CV) manifestations have been reported. SARS coronavirus 2 infection can lead to inflammatory CV disease first via takeover of the angiotensin-converting enzyme-2 enzyme as a cell receptor as well as the macrophage activation syndrome in severe illness. We review the CV manifestations of COVID-19 and therapeutics under investigation. We discuss the potential long-term CV sequelae after recovery from COVID-19 and the gaps in knowledge including the pathophysiological links between acute cardiac injury, myocardial inflammation and chronic cardiomyopathy. Future investigational efforts could result in significant diagnostic and therapeutic advances potentially impacting the broader field of chronic heart failure and cardiac recovery.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.2217/fca-2020-0188DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7986052PMC
March 2021

Predicting mortality in cardiogenic shock secondary to ACS requiring short-term mechanical circulatory support: The ACS-MCS score.

Catheter Cardiovasc Interv 2021 Mar 7. Epub 2021 Mar 7.

Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA.

Objective: To identify predictors of 30-day all-cause mortality for patients with cardiogenic shock secondary to acute coronary syndrome (ACS-CS) who require short-term mechanical circulatory support (ST-MCS).

Background: ACS-CS mortality is high. ST-MCS is an attractive treatment option for hemodynamic support and stabilization of deteriorating patients. Mortality prediction modeling for ACS-CS patients requiring ST-MCS has not been well-defined.

Methods: The Utah Cardiac Recovery (UCAR) Shock database was used to identify patients admitted with ACS-CS requiring ST-MCS devices between May 2008 and August 2018. Pre-ST-MCS clinical, laboratory, echocardiographic, and angiographic data were collected. The primary endpoint was 30-day all-cause mortality. A weighted score comprising of pre-ST-MCS variables independently associated with 30-day all-cause mortality was derived and internally validated.

Results: A total of 159 patients (mean age, 61 years; 78% male) were included. Thirty-day all-cause mortality was 49%. Multivariable analysis resulted in four independent predictors of 30-day all-cause mortality: age, lactate, SCAI CS classification, and acute kidney injury. The model had good calibration and discrimination (area under the receiver operating characteristics curve 0.80). A predictive score (ranging 0-4) comprised of age ≥ 60 years, pre-ST-MCS lactate ≥2.5 mmol/L, AKI at time of ST-MCS implementation, and SCAI CS stage E effectively risk stratified our patient population.

Conclusion: The ACS-MCS score is a simple and practical predictive score to risk-stratify CS secondary to ACS patients based on their mortality risk. Effective mortality risk assessment for ACS-CS patients could have implications on patient selection for available therapeutic strategy options.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/ccd.29581DOI Listing
March 2021

Challenges and the innovations in the care of advanced heart failure patients during COVID-19.

Heart Fail Rev 2021 Jan 12. Epub 2021 Jan 12.

Smidt Heart Institute, Cedars-Sinai, Los Angeles, CA, USA.

The COVID-19 pandemic underscored our healthcare system's unpreparedness to manage an unprecedented pandemic. Heart failure (HF) physicians from 14 different academic and private practice centers share their systems' challenges and innovations to care for patients with HF, heart transplantation, and patients on LVAD support during the COVID-19 pandemic. We discuss measures implemented to alleviate the fear in seeking care, ensure continued optimization of guideline directed medical therapy (GDMT), manage the heart transplant waiting list, continue essential outpatient monitoring of anticoagulation in LVAD patients and surveillance testing post-heart transplant, and prevent physician burnout. This collaborative work can build a foundation for better preparation in the face of future challenges.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s10741-021-10074-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7801155PMC
January 2021

Fifty-second flat-line: A dramatic case of ictal asystole.

HeartRhythm Case Rep 2020 Oct 18;6(10):794-797. Epub 2020 Aug 18.

UCLA Cardio-Oncology Program, Division of Cardiology, Department of Medicine, University of California at Los Angeles, Los Angeles, California.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.hrcr.2020.08.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7573472PMC
October 2020

Tissue Is the Issue, Even During a Pandemic.

Circulation 2020 08 15;142(5):423-425. Epub 2020 Jun 15.

Division of Cardiovascular Medicine, Department of Medicine, University of Utah Health Science Center, Salt Lake City (K.S.S., J.C.F.).

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1161/CIRCULATIONAHA.120.047944DOI Listing
August 2020

Cerebral Amyloid Angiopathy-Related Inflammation in the Immunosuppressed: A Case Report.

Front Neurol 2019 6;10:1283. Epub 2019 Dec 6.

Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA, United States.

Cerebral amyloid angiopathy-related inflammation (CAA-ri) is an immune-mediated disorder of the central nervous system characterized by an inflammatory response to amyloid-beta (Aβ) deposition within cerebral blood vessel walls. Immunosuppressive therapy is the mainstay of treatment. We present a case of CAA-ri in a subject already on immunosuppressive therapy after orthotopic heart transplantation (OHT). A 57-year-old man 8 months post-OHT for sarcoid cardiomyopathy developed headaches and staring spells while hospitalized for disseminated mycobacterial infection. His brain MRI revealed bi-hemispheric T2-weighted fluid-attenuated inversion recovery white matter hyperintensities and widespread microhemorrhages. Two weeks later, he developed gait ataxia and alterations in mental status, and repeat brain MRI showed more extensive confluent white matter hyperintensities. Leptomeningeal and cortex biopsy revealed changes consistent with amyloid angiitis, with perivascular and intramural histiocyte and lymphocyte collections. Mass spectroscopy confirmed Aβ deposition. Notably, the patient was on immunosuppression with daily 5 mg oral prednisone and tacrolimus before biopsy. After high-dose intravenous followed by oral corticosteroids, he demonstrated significant clinical and radiographic improvement. No relapse was noted despite the relatively rapid tapering of the prednisone therapy over 3 months, as mandated by his systemic infection. Despite the lack of a standard treatment protocol for CAA-ri, case series have reinforced the benefit of prolonged courses of glucocorticoids as single agent or in combination with other immunomodulatory agents. Hence, management of CAA-ri in patients with disseminated mycobacterial infections or OHT is challenging. Our case is unique, as review of existing literature has not revealed any similar cases of patients on chronic immunosuppression at the time of CAA-ri diagnosis, which one would expect to protect against this disorder. In addition, CAA-ri in association with cardiopulmonary sarcoidosis was not previously reported; however, a common immunopathogenic mechanism may exist.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3389/fneur.2019.01283DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6908508PMC
December 2019

Amyloid and the Heart.

Curr Cardiol Rep 2019 12 3;21(12):164. Epub 2019 Dec 3.

Heart Transplant Program, Cardiac Amyloidosis Program, 8536 Wilshire Blvd, 3rd floor, Beverly Hills, CA, 90211, USA.

Purpose Of Review: While morbidity and mortality remain high for amyloid cardiomyopathy (AC), increased awareness, earlier diagnosis, and advances in treatment have improved patient outcomes. This review will discuss the pathophysiology, contemporary diagnostic strategies, and novel and investigational therapeutic strategies for light-chain (AL) and transthyretin (ATTR) AC.

Recent Findings: Diagnostic strategies for AC now include cardiac magnetic resonance imaging and bone scintigraphy. Proteosome inhibitor therapy is now front-line therapy for AL AC followed by autologous stem cell transplantation. Emerging disease-modifying strategies for ATTR AC include the recently FDA-approved TTR-stabilizer, tafamadis. ATTR gene-silencing therapy and amyloid fibril degradation therapy are two other strategies under investigation. Heart transplantation and durable mechanical circulatory support remain a final potential option; however, contemporary outcomes are improving with better patient selection. Patient outcomes for AC are expected to improve as increased awareness leads to earlier diagnosis and prompt treatment with emerging pharmacotherapy or advanced heart therapies.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s11886-019-1230-9DOI Listing
December 2019

Coronary computed tomography-angiography quantitative plaque analysis improves detection of early cardiac allograft vasculopathy: A pilot study.

Am J Transplant 2020 05 21;20(5):1375-1383. Epub 2019 Dec 21.

Department of Imaging, Medicine, and Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, California, USA.

Cardiac allograft vasculopathy (CAV) is an increasingly important complication after cardiac transplant. We assessed the additive diagnostic benefit of quantitative plaque analysis in patients undergoing coronary computed tomography-angiography (CCTA). Consecutive patients undergoing CCTA for CAV surveillance were identified. Scans were visually interpreted for coronary stenosis. Semiautomated software was used to quantify noncalcified plaque (NCP), as well as its components. Optimal diagnostic cut-offs for CAV, with coronary angiography as gold standard, were defined using receiver operating characteristic curves. In total, 36 scans were identified in 17 patients. CAV was present in 17 (46.0%) reference coronary angiograms, at a median of 1.9 years before CCTA. Median NCP (147 vs 58, P < .001), low-density NCP (median 4.5 vs 0.9, P = .003), fibrous plaque (median 76.1 vs 31.1, P = .003), and fibrofatty plaque (median 63.6 vs 27.6, P < .001) volumes were higher in patients with CAV, whereas calcified plaque was not (median 0.0 vs 0.0, P = .510). Visual assessment of CCTA alone was 70.6% sensitive and 100% specific for CAV. The addition of total NCP volume increased sensitivity to 82.4% while maintaining 100% specificity. NCP volume is significantly higher in patients with CAV. The addition of quantitative analysis to visual interpretation improves the sensitivity for detecting CAV without reducing specificity.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/ajt.15721DOI Listing
May 2020

Treating the Cardiorenal Syndrome: A Sledgehammer for a Needle's Work?

J Card Fail 2019 11 31;25(11):935-936. Epub 2019 Oct 31.

University of Utah Health, Salt Lake City, Utah.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.cardfail.2019.10.010DOI Listing
November 2019

Is Heart Failure with Preserved Ejection Fraction a Kidney Disorder?

Curr Hypertens Rep 2019 10 10;21(11):86. Epub 2019 Oct 10.

Division of Cardiovascular Medicine, University of Utah School of Medicine, 30 North, 1900 East, Rm 4A100 SOM, Salt Lake City, UT, 84132, USA.

Purpose Of Review: Heart failure with preserved ejection fraction (HFpEF) is a heterogeneous syndrome of exertional intolerance, cardiac dysfunction, and fluid overload and is associated with significant morbidity and mortality.

Recent Findings: As our understanding of this syndrome has evolved, we are beginning to recognize the similarities and associations with chronic kidney disease (CKD). Salt and fluid retention are common in CKD and may be the sentinel event leading ultimately to the syndrome of HFpEF. Mechanisms linking both disease states include hypervolemia, inflammation, and endothelial dysfunction, which are also common to comorbidities that drive both HFpEF and CKD. In this review, we will discuss recent clinical research focusing on HFpEF, CKD, and comorbidities including hypertension and diabetes mellitus. We will review strategies for volume management and novel therapeutic approaches with new classes of drugs, including sodium-glucose cotransporters and angiotensin receptor/neprilysin inhibitors, which may work through targeting of both the heart and the kidney. Lastly, we emphasize why focusing on the alleviation of factors provoking renal injury and slowing the progression of renal dysfunction may provide the most therapeutic benefit in patients who have been diagnosed with HFpEF.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s11906-019-0993-0DOI Listing
October 2019

Prescription opioid use before and after heart transplant: Associations with posttransplant outcomes.

Am J Transplant 2019 12 12;19(12):3405-3414. Epub 2019 Sep 12.

Center for Abdominal Transplantation, Saint Louis University School of Medicine, St. Louis, Missouri.

Impacts of the prescription opioid epidemic have not yet been examined in the context of heart transplantation. We examined a novel database in which national U.S. transplant registry records were linked to a large pharmaceutical claims warehouse (2007-2016) to characterize prescription opioid use before and after heart transplant, and associations (adjusted hazard ratio, aHR ) with death and graft loss. Among 13 958 eligible patients, 40% filled opioids in the year before transplant. Use was more common among recipients who were female, white, or unemployed, or who underwent transplant in more recent years. Of those with the highest level of pretransplant opioid use, 71% continued opioid use posttransplant. Pretransplant use had graded associations with 1-year posttransplant outcomes; compared with no use, the highest-level use (>1000 mg morphine equivalents) predicted 33% increased risk of death (aHR 1.33 ) in the year after transplant. Risk relationships with opioid use in the first year posttransplant were stronger, with highest level use predicting 70% higher mortality (aHR 1.70 ) over the subsequent 4 years (from >1 to 5 years posttransplant). While associations may, in part, reflect underlying conditions or behaviors, opioid use history is relevant in assessing and providing care to transplant candidates and recipients.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/ajt.15565DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6883129PMC
December 2019

Updates on Heart Transplantation.

Curr Heart Fail Rep 2019 10;16(5):150-156

Cedars-Sinai Smidt Heart Institute, Los Angeles, CA, USA.

Purpose Of Review: The purpose of this review is to provide a comprehensive update on recent advances in heart transplantation.

Recent Findings: Heart transplantation is now an established therapy for end-stage heart failure, though challenges still exist. However, multiple advances over the past few years will improve the survival and quality of life of heart transplant recipients. These advances include acceptance of previously considered marginal donor hearts, revisions to the donor heart allocation policy, advances in desensitization regimens, tailoring of immunosuppression regimens, and improvement in the diagnosis of rejection and allograft vasculopathy. Heart transplantation is evolving to provide better quality of life and survival to higher risk recipients with methods to broaden the donor pool, make the best use of existing organs, and refine the management of sensitization and diagnosis of rejection and allograft vasculopathy.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s11897-019-00432-3DOI Listing
October 2019

Desensitization in heart transplant recipients: Who, when, and how.

Clin Transplant 2019 08 4;33(8):e13639. Epub 2019 Jul 4.

Cedars-Sinai Smidt Heart Institute, Los Angeles, California.

The number of heart transplant candidates who have pre-formed antibodies against human leukocyte antigens (HLAs) is increasing over time. The purpose of this review is to discuss the process of antibody desensitization for heart transplant candidates. Specifically, we review the current status of antibody detection including identification, strength, and potential pathogenicity. We discuss which patients and when should they undergo desensitization therapies during heart transplant evaluation. Specific therapies including mechanical removal of antibodies, intravenous immunoglobulins, and novel immunosuppressive agents targeting antibody production will be discussed. Finally, future research strategies to develop novel desensitization therapies for heart transplant candidates will be reviewed.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/ctr.13639DOI Listing
August 2019

Utilizing Biomarkers to Refine Risk Prediction in Atrial Fibrillation: A Step Toward Precision Medicine.

J Am Coll Cardiol 2019 04;73(12):1411-1412

Smidt Heart Institute, Cedars-Sinai, Los Angeles, California.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jacc.2018.10.092DOI Listing
April 2019

Atherosclerotic Cardiovascular Disease in South Asians in the United States: Epidemiology, Risk Factors, and Treatments: A Scientific Statement From the American Heart Association.

Circulation 2018 07 24;138(1):e1-e34. Epub 2018 May 24.

South Asians (from Bangladesh, Bhutan, India, the Maldives, Nepal, Pakistan, and Sri Lanka) make up one quarter of the world's population and are one of the fastest-growing ethnic groups in the United States. Although native South Asians share genetic and cultural risk factors with South Asians abroad, South Asians in the United States can differ in socioeconomic status, education, healthcare behaviors, attitudes, and health insurance, which can affect their risk and the treatment and outcomes of atherosclerotic cardiovascular disease (ASCVD). South Asians have higher proportional mortality rates from ASCVD compared with other Asian groups and non-Hispanic whites, in contrast to the finding that Asian Americans (Asian Indian, Chinese, Filipino, Japanese, Korean, and Vietnamese) aggregated as a group are at lower risk of ASCVD, largely because of the lower risk observed in East Asian populations. Literature relevant to South Asian populations regarding demographics and risk factors, health behaviors, and interventions, including physical activity, diet, medications, and community strategies, is summarized. The evidence to date is that the biology of ASCVD is complex but is no different in South Asians than in any other racial/ethnic group. A majority of the risk in South Asians can be explained by the increased prevalence of known risk factors, especially those related to insulin resistance, and no unique risk factors in this population have been found. This scientific statement focuses on how ASCVD risk factors affect the South Asian population in order to make recommendations for clinical strategies to reduce disease and for directions for future research to reduce ASCVD in this population.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1161/CIR.0000000000000580DOI Listing
July 2018

Troponin in Heart Failure.

Heart Fail Clin 2018 Jan;14(1):57-64

Division of Cardiology, Department of Medicine, Ronald Reagan UCLA Medical Center, 10833 LeConte Avenue, Room A2-237 CHS, Los Angeles, CA 90095-1679, USA.

Cardiac troponin is an integral biomarker in the evaluation and management of patients with acute coronary syndrome. Troponin is also established as a valuable prognostic marker in patients with acute or chronic heart failure (HF). As the sensitivity of troponin assays transition to high sensitive troponin, more patients with HF will have detectable troponin. In this review, the authors discuss the current literature on the value of troponin in the management of patients with HF. Furthermore, the authors highlight the potential for future strategies to use troponin as a potential target for therapy in patients with HF.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.hfc.2017.08.007DOI Listing
January 2018

Heart Failure With Preserved, Borderline, and Reduced Ejection Fraction: 5-Year Outcomes.

J Am Coll Cardiol 2017 11 12;70(20):2476-2486. Epub 2017 Nov 12.

Department of Medicine, Division of Cardiology, University of California, Los Angeles, Los Angeles, California; Department of Medicine, Division of Cardiology/Ahmanson-UCLA Cardiomyopathy Center, University of California, Los Angeles, Los Angeles, California. Electronic address:

Background: Patients with heart failure (HF) have a poor prognosis and are categorized by ejection fraction (EF).

Objectives: This study sought to characterize differences in outcomes in patients hospitalized with heart failure with preserved ejection fraction (HFpEF) (EF ≥50%), heart failure with borderline ejection fraction (HFbEF) (EF 41% to 49%), and heart failure with reduced ejection fraction (HFrEF) (EF ≤40%).

Methods: Data from GWTG-HF (Get With The Guidelines-Heart Failure) were linked to Medicare data for longitudinal follow-up. Multivariable models were constructed to examine 5-year outcomes and to compare survival to median survival of the U.S.

Population:

Results: A total of 39,982 patients from 254 hospitals who were admitted for HF between 2005 and 2009 were included: 18,299 (46%) had HFpEF, 3,285 (8.2%) had HFbEF, and 18,398 (46%) had HFrEF. Overall, median survival was 2.1 years. In risk-adjusted survival analysis, all 3 groups had similar 5-year mortality (HFrEF 75.3% vs. HFpEF 75.7%; hazard ratio: 0.99 [95% confidence interval: 0.958 to 1.022]; HFbEF 75.7% vs. HFpEF 75.7%; hazard ratio: 0.99 [95% confidence interval: 0.947 to 1.046]). In risk-adjusted analyses, the composite of mortality and rehospitalization was similar for all subgroups. Cardiovascular and HF readmission rates were higher in those with HFrEF and HFbEF compared with those with HFpEF. When compared with the U.S. population, HF patients across all age and EF groups had markedly lower median survival.

Conclusions: Among patients hospitalized with HF, patients across the EF spectrum have a similarly poor 5-year survival with an elevated risk for cardiovascular and HF admission. These findings underscore the need to improve treatment of patients with HF.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jacc.2017.08.074DOI Listing
November 2017

The Role of Biomarkers in Detection of Cardio-toxicity.

Curr Oncol Rep 2017 Jun;19(6):42

Division of Cardiology, University of California, Los Angeles, 650 Charles E. Young Dr. South, A2-237 CHS, MC: 167917, Los Angeles, CA, 90095, USA.

The goal of this paper is to review the current literature on the role of biomarkers in the detection and management of patients with cardio-oncologic disease. The role of biomarker surveillance in patients with known cardiac disease, as a result of chemotherapy or with the potential to develop cardio-toxicity, will be discussed. In addition, the studies surrounding sub-clinical cardiac toxicity monitoring during therapy, identification of high-risk patients prior to therapy, and tailoring oncologic therapies to potential biomarker risk profiles are reviewed. Based on evidence, to date, troponin and natriuretic peptides have the greatest potential to detect sub-clinical cardiac dysfunction and even tailor therapy to prevent progression based on biomarker profiles. Finally, future directions for potential utilization of novel biomarkers for the improvement of care of patients in the field of cardio-oncology are discussed.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s11912-017-0602-9DOI Listing
June 2017

How B-Type Natriuretic Peptide (BNP) and Body Weight Changes Vary in Heart Failure With Preserved Ejection Fraction Compared With Reduced Ejection Fraction: Secondary Results of the HABIT (HF Assessment With BNP in the Home) Trial.

J Card Fail 2016 Apr 31;22(4):283-93. Epub 2015 Oct 31.

Division of Cardiology, University of California, San Diego, California.

Background: Heart failure is a common cause of hospitalization and can be divided into types with preserved and reduced ejection fraction (HFpEF and HFrEF, respectively). In this subanalysis of the HABIT (Heart Failure Assessment With BNP in the Home) trial, we examined the differences between home B-type natriuretic peptide (BNP) testing and weight monitoring in patients with HFpEF and with HFrEF before decompensation.

Methods And Results: This was a retrospective review of patients with HFpEF and HFrEF from the HABIT trial. The HFpEF patients compared with HFrEF patients were older and more obese and had lower baseline BNP values. Intra-individual BNP dispersion (spread of distribution over time) was greater in HFpEF than in HFrEF owing to rapid fluctuations (within 3 days). Slowly varying changes in BNP (estimated by a moving average) were equally predictive of ADHF risk in both HFpEF and HFrEF. However, in HFpEF, a rapid rise in BNP >200 pg/mL within 3 days was associated with an increased risk of acute decompensated heart failure (ADHF; hazard ratio 4.0), whereas a similar association was not observed in HFrEF. Weight gain ≥5 lb in 3 days had a high specificity but low sensitivity for ADHF in both HFpEF and HFrEF, whereas a lower threshold of ≥2 lb weight gain over 3 days in patients with HFpEF (but not HFrEF) was a moderately sensitive cutoff associated with decompensation (60% sensitivity).

Conclusions: Patients with HFpEF and HFrEF have variations in their BNP and weight before decompensation. The rapid time scale behaves differently between the groups. In those with HFpEF, a 3-day period characterized by ≥2 lb weight gain and/or >200 pg/mL BNP rise was significantly associated with decompensation. Future prospective studies investigating different weight and BNP cutoffs for home monitoring of HFpEF and HFrEF patients should be performed to fully learn the value of BNP changes before clinical deompensation.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.cardfail.2015.09.014DOI Listing
April 2016

Serial sampling of copeptin levels improves diagnosis and risk stratification in patients presenting with chest pain: results from the CHOPIN trial.

Emerg Med J 2016 Jan 23;33(1):23-9. Epub 2015 Jun 23.

University of California, San Diego, California, USA Veterans Affairs Medical Center, San Diego, California, USA.

Background: Copeptin has demonstrated a role in early rule out for acute myocardial infarction (AMI) in combination with a negative troponin. However, management of patients with chest pain with a positive copeptin in the setting of a negative troponin is unclear.

Methods: The multicentre CHOPIN trial enrolled 2071 patients with acute chest pain. Of these, 476 subjects with an initial negative troponin but an elevated copeptin (>14 pmol/L) were included in this study. Copeptin and troponin levels were rechecked at 2 h and the final diagnosis of AMI was made by two independent, blinded cardiologists. Follow-up at 30 days was obtained for major adverse cardiac events (MACEs), including death, AMI and urgent revascularisation.

Results: Of the 476 patients analysed, 365 (76.7%) had a persistently elevated copeptin at 2 h and 111 patients (23.3%) had a copeptin that fell below the cut-off of 14 pmol/L. When the second copeptin was elevated there were 18 AMIs (4.9%) compared with 0 (0%) when the second copeptin was negative (p=0.017), yielding a negative predictive value of 100% (95% CI 96.7% to 100%). On 30-day follow-up there were 36 MACEs (9.9%) in the positive second copeptin group and 2 (1.8%) MACEs in the negative second copeptin group (p=0.006).

Conclusions: Patients with chest pain with an initial negative troponin but positive copeptin are common and carry an intermediate risk of AMI. A second copeptin drawn 2 h after presentation may help risk stratify and potentially rule out AMI in this cohort.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1136/emermed-2015-204692DOI Listing
January 2016

Midregional proadrenomedullin predicts mortality and major adverse cardiac events in patients presenting with chest pain: results from the CHOPIN trial.

Acad Emerg Med 2015 May 23;22(5):554-63. Epub 2015 Apr 23.

Department of Cardiology, University of California, San Diego, CA.

Objectives: Chest pain is a common complaint to emergency departments (EDs) and clinical risk factors are used to predict which patients are at risk for worse outcomes and mortality. The goal was to assess the novel biomarker midregional proadrenomedullin (MR-proADM) in prediction of mortality and major adverse cardiac events (MACE).

Methods: This was a subanalysis of the CHOPIN study, a 16-center prospective trial that enrolled 2,071 patients presenting with chest pain within 6 hours of onset. The primary endpoint was 6-month all-cause mortality and the secondary endpoint was 30-day and 6-month MACE: ED visits or hospitalization for acute myocardial infarction, unstable angina, reinfarction, revascularization, and heart failure.

Results: MR-proADM performed similarly to troponin (cTnI; c-statistic = 0.845 and 0.794, respectively) for mortality prediction in all subjects and had similar results in those with noncardiac diagnoses. MR-proADM concentrations were stratified by decile, and the cohort in the top decile had a 9.8% 6-month mortality risk versus 0.9% risk for those in the bottom nine deciles (p < 0.0001). MR-proADM, history of coronary artery disease (CAD), and hypertension were predictors of short-term MACE, while history of CAD, hypertension, cTnI, and MR-proADM were predictors of long-term MACE.

Conclusions: In patients with chest pain, MR-proADM predicts mortality and MACE in all-comers with chest pain and has similar prediction in those with a noncardiac diagnosis. This exploratory analysis is primarily hypotheses-generating and future prospective studies to identify its utility in risk stratification should be considered.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/acem.12649DOI Listing
May 2015

Proenkephalin predicts acute kidney injury in cardiac surgery patients.

Clin Nephrol 2015 Jan;83(1):29-35

Department of Internal Medicine, Department of Cardiology, University of California San Diego, VA San Diego Healthcare System, San Diego, CA, USA, and Sphingotec GmbH, Hennigsdorf, Germany.

Aims: Acute kidney injury (AKI) occurs in up to 40% of patients undergoing cardiac surgery. Proenkephalin A 119-159 (pro-ENK) is a novel, stable surrogate biomarker for enkephalins, endogenous opioids involved in various physiological processes, including neurohormonal stress.

Material And Methods: 92 patients undergoing cardiac surgery at the Veterans Affairs San Diego Healthcare System had a post-hoc analysis performed to determine the ability of pro-ENK to predict AKI as well as to compare it against other risk factors for development of AKI.

Results: Of 92 patients, 20 patients developed AKI post-operatively. Pro-ENK levels were significantly elevated in patients who develop AKI. Log pro-ENK value pre-operatively has an odds ratio of 23.8 (p = 0.011, 95% CI = 2 - 270) in its association with AKI. Pro-ENK performs similarly to baseline creatinine in its ability to predict post-operative AKI. Importantly, pro-ENK has a strong positive correlation with creatinine (r = 0.806). Additionally, changes in pro-ENK level, from pre-operatively to 12 hours post-operatively have greatest area under curve by ROC analysis for AKI after post-operative day 1.

Conclusion: Pro-ENK is associated with prediction of AKI in patients undergoing cardiac surgery. Pro-ENK likely has decreased clearance in the setting of AKI. However, future studies analyzing this novel biomarker should be considered to further elucidate its clinical utility and to better understand mechanisms of renal injury.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.5414/cn108387DOI Listing
January 2015

Novel biomarkers in heart failure with preserved ejection fraction.

Heart Fail Clin 2014 Jul;10(3):471-9

Cardiology Section (9111-A), VA San Diego Healthcare System, 3350 La Jolla Village Drive, San Diego, CA 92161, USA. Electronic address:

Heart failure with preserved ejection fraction (HFPEF) is a common subtype of heart failure with morbidity and mortality similar to that of heart failure with systolic dysfunction. This article discusses the numerous biomarkers that promise to play a substantial role in terms of our ability to understand the mechanisms of HFPEF and discern possible phenotypes that respond to targeted therapies: natriuretic peptides, high-sensitivity troponins, galectin-3, soluble ST2, neutrophil gelatinase-associated lipocalin, and cystatin C.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.hfc.2014.04.005DOI Listing
July 2014

Acoustic cardiography S3 detection use in problematic subgroups and B-type natriuretic peptide "gray zone": secondary results from the Heart failure and Audicor technology for Rapid Diagnosis and Initial Treatment Multinational Investigation.

Am J Emerg Med 2011 Oct 13;29(8):924-31. Epub 2010 Jul 13.

Division of Cardiology, Veterans Affairs San Diego Health care System, San Diego, CA 92161, USA.

Background: Dyspneic emergency department (ED) patients present a diagnostic dilemma. The S3, although highly specific for acute heart failure (AHF) and predicting death and readmission, is often difficult to auscultate. The HEart failure and Audicor technology for Rapid Diagnosis and Initial Treatment (HEARD-IT) multinational trial evaluated the S3 via acoustic cardiography (Audicor). Our goal in this secondary analysis was to determine if the strength of the S3 can provide diagnostic/prognostic information in problematic heart failure subgroups.

Methods: Dyspneic ED patients older than 40 years and not on dialysis were prospectively enrolled. A gold standard AHF diagnosis was determined by 2 cardiologists blinded to acoustic cardiography results. The S3 strength parameter was delineated on a scale of 0 to 10. This secondary analysis of subgroups from the HEARD-IT database used univariate/multivariate regression to determine the diagnostic/prognostic ability of the S3 strength.

Results: In the 995 patients enrolled, S3 strength was a significant prognosticator in univariate analysis for adverse events but not in a multivariable model. In patients with "gray zone" B-type natriuretic peptide (BNP) levels (100-499 pg/mL), acoustic cardiography increased diagnostic accuracy of AHF from 47% to 69%. Acoustic cardiography improved S3 detection sensitivity in obese patients when compared to auscultation.

Conclusion: The strength of the S3 gallop provides rapid results that assist with identification of AHF in selected populations. S3 detection complements the use of BNP in the gray zone, and its diagnostic/prognostic ability is largely unaffected by body mass index and renal function. S3 strength shows promise as a diagnostic and prognostic tool in problematic HF subgroups.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ajem.2010.03.032DOI Listing
October 2011