Publications by authors named "Patricia Chang"

150 Publications

Examining Information Needs of Heart Failure Patients and Family Companions using a Pre-Visit Question Prompt List and Audiotaped Data: Findings from a Pilot Study.

J Card Fail 2021 Nov 21. Epub 2021 Nov 21.

University of North Carolina, Chapel Hill, USA; Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, USA. Electronic address:

Background: Question prompt lists (QPLs) are an effective tool for improving communication during medical visits. However, no studies have attempted to correlate intentions related to question asking and actual questions asked during visits. Moreover, few studies have used QPLs with patients with Heart Failure (HF) or family companions who accompany them to visits. We examined the usage of a pre-visit QPL for patients with HF and their family companions intended to enhance engagement in HF care. The aim of this research was to assess which questions from the QPL patients and companions selected most frequently to ask and compare this to which questions were actually asked during the medical visit.

Methods: This is a secondary analysis of question prompt list and audiotaped visit data from a pilot study which enrolled and consented HF patients, family companions, and heart failure clinicians. A single group of 30 HF patients and 23 family companions received the QPL to complete in the waiting room immediately before their cardiology visit. To meet our aims, we calculated frequencies for each question selected and asked from the QPL, using data derived from completed prompt lists and audiotaped medical visits. A follow-up survey was administered 2 days after the appointment to assess differences in how participants filled out and used the prompt list.

Results: Patients and companions primarily selected and asked questions from the QPL regarding management and treatment of the disease, general questions about HF, and questions about prognosis. Participants rarely asked questions about support for family and friends or healthcare team roles and responsibilities. Patients and companions did not ask many of the questions they reported wanting to ask.

Conclusion: Prompt lists may empower patients and companions to communicate with their clinician by identifying important questions to help overcome patients' and companions' knowledge gaps. More research is needed to understand the true impact of prompt lists on patient-family-clinician communication and subsequent HF outcomes, and how best to implement them in clinical workflows to increase their potential utility.
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http://dx.doi.org/10.1016/j.cardfail.2021.11.012DOI Listing
November 2021

Unexpected Case of Chagas Disease Reactivation in Endomyocardial Biopsy for Evaluation of Cardiac Allograft Rejection.

Cardiovasc Pathol 2021 Nov 3:107394. Epub 2021 Nov 3.

The University of North Carolina at Chapel Hill, Department of Pathology and Laboratory Medicine. Electronic address:

Acute Chagas disease reactivation (CDR) after cardiac transplantation is a well-known phenomenon in endemic countries of Central and South America and Mexico, but is rare outside of those countries. In this report, we describe a case of a 49 year old male who presented 25 weeks after heart transplant with clinical features concerning for acute rejection, including malaise, anorexia, weight loss, and fever. His immunosuppression therapy included tacrolimus, mycophenolate, and prednisone. An endomyocardial biopsy revealed lymphocytic and eosinophilic inflammation, myocyte damage, and rare foci of intracellular organisms consistent with Trypanosoma cruzi amastigotes. The patient had no known history of Chagas disease. Upon additional questioning, the patient endorsed bites from reduviid bugs during childhood in El Salvador. Follow-up serum PCR testing was positive for T. cruzi DNA. Tests for other infectious organisms and donor specific antibodies were negative. This case illustrates the striking clinical and histologic similarities between acute cellular rejection and acute CDR with cardiac involvement in heart transplant patients, and thus emphasizes the importance of pre-transplant testing for Chagas in patients with epidemiologic risk factors.
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http://dx.doi.org/10.1016/j.carpath.2021.107394DOI Listing
November 2021

Effect of government-issued state of emergency and reopening orders on cardiovascular hospitalizations during the COVID-19 pandemic.

Am J Prev Cardiol 2021 Jun 17;6. Epub 2021 Mar 17.

Division of Cardiology, University of North Carolina School of Medicine, Chapel Hill, NC.

Objective: Little is known about the effect of government-issued State of Emergency (SOE) and Reopening orders on health care behaviors. We aimed to determine the effect of SOE and Phase 1 of Reopening orders on hospitalizations for acute myocardial infarction (AMI) or acute decompensated heart failure (ADHF).

Methods: Hospitalizations for AMI and ADHF in the UNC Health system, which includes 10 hospitals in both urban and rural counties, were identified. An interrupted time series design was used to compare weekly hospitalization rates for eight weeks before the March 10 SOE declaration, eight weeks between the SOE order and Phase 1 of Reopening order, and the subsequent eight weeks.

Results: Overall, 3,792 hospitalizations for AMI and 7,223 for ADHF were identified. Rates before March 10 were stable. AMI/ADHF hospitalizations declined about 6% per week in both urban and rural hospitals from March 11 to May 5. Larger declines in hospitalizations were seen in adults ≥65 years old (-8% per week), women (-7% per week), and White individuals (-6% per week). After the Reopening order, AMI/ADHF hospitalizations increased by 8% per week in urban centers and 9% per week in rural centers, including a significant increase in each demographic group. The decline and rebound in acute CV hospitalizations were most pronounced in the two weeks following the government orders.

Conclusions: AMI and ADHF hospitalization rates closely correlated to SOE and Reopening orders. These data highlight the impact of public health measures on individuals seeking care for essential services; future policies may benefit from clarity regarding when individuals should present for care.
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http://dx.doi.org/10.1016/j.ajpc.2021.100172DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8312728PMC
June 2021

Epidemiology of Heart Failure Stages in Middle-Aged Black People in the Community: Prevalence and Prognosis in the Atherosclerosis Risk in Communities Study.

J Am Heart Assoc 2021 05 21;10(9):e016524. Epub 2021 Apr 21.

Department of Medicine University of Mississippi Medical Center Jackson MS.

Background Black individuals have a higher burden of risk factors for heart failure (HF) and subclinical left ventricular remodeling. Methods and Results We evaluated 1871 Black participants in the Atherosclerosis Risk in Communities Study cohort who attended a routine examination (1993-1996, median age 58 years) when they underwent echocardiography. We estimated the prevalences of 4 HF stages: (1) : no risk factors; (2) : presence of HF risk factors (hypertension, diabetes mellitus, obesity, smoking, dyslipidemia, coronary artery disease without clinical myocardial infarction), no cardiac structural/functional abnormality; (3) : presence of prior myocardial infarction, systolic dysfunction, left ventricular hypertrophy, regional wall motion abnormality, or left ventricular enlargement; and (4) : prevalent HF. We assessed the incidence of clinical HF, atherosclerotic cardiovascular disease events, and all-cause mortality on follow-up according to HF stage. The prevalence of HF Stages 0, A, B, and C/D were 3.8%, 20.6%, 67.0%, and 8.6%, respectively, at baseline. On follow-up (median 19.0 years), 309 participants developed overt HF, 390 incurred new-onset cardiovascular disease events, and 651 individuals died. Incidence rates per 1000 person-years for overt HF, cardiovascular disease events, and death, respectively, were Stage 0, 2.4, 0.8, and 7.6; Stage A, 7.4, 9.7, and 13.5; Stage B 13.6, 15.9, and 22.0. Stage B HF was associated with a 1.5- to 2-fold increased adjusted risk of HF, cardiovascular disease events and death compared with Stages 0/A. Conclusions In our large community-based sample of Black individuals, we observed a strikingly high prevalence of Stage B HF in middle age that was a marker of high cardiovascular morbidity and mortality.
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http://dx.doi.org/10.1161/JAHA.120.016524DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8200743PMC
May 2021

Racial Differences and Temporal Obesity Trends in Heart Failure with Preserved Ejection Fraction.

J Am Geriatr Soc 2021 05 5;69(5):1309-1318. Epub 2021 Jan 5.

Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern, Dallas, Texas, USA.

Background/objectives: Obesity increases with age, is disproportionately prevalent in black populations, and is associated with heart failure with preserved ejection fraction (HFpEF). An "obesity paradox," or improved survival with obesity, has been reported in patients with HFpEF. The aim of this study was to examine whether racial differences exist in the temporal trends and outcomes associated with obesity among older patients with HFpEF.

Design: Community surveillance of acute decompensated heart failure (ADHF) hospitalizations, sampled by stratified design from 2005 to 2014.

Setting: Atherosclerosis Risk in Communities Study (NC, MS, MD, MN).

Participants: A total of 10,147 weighted hospitalizations for ADHF (64% female, 74% white, mean age 77 years), with ejection fraction ≥50%.

Measurements: ADHF classified by physician review, HFpEF defined by ejection fraction ≥50%. Body mass index (BMI) calculated from weight at hospital discharge. Obesity defined by BMI ≥30 kg/m , class III obesity by BMI ≥40 kg/m .

Results: When aggregated across 2005-2014, the mean BMI was higher for black compared to white patients (34 vs 30 kg/m ; P < .0001), as was prevalence of obesity (56% vs 43%; P < .0001) and class III obesity (24% vs 13%; P < .0001). Over time, the annual mean BMI and prevalence of class III obesity remained stable for black patients, but steadily increased for white patients, with annual rates statistically differing by race (P-interaction = .04 and P = .03, respectively). For both races, a U-shaped adjusted mortality risk was observed across BMI categories, with the highest risk among patients with a BMI ≥40 kg/m .

Conclusion: Black patients were disproportionately burdened by obesity in this decade-long community surveillance of older hospitalized patients with HFpEF. However, temporal increases in mean BMI and class III obesity prevalence among white patients narrowed the racial difference in recent years. For both races, the worst survival was observed with class III obesity. Effective strategies are needed to manage obesity in patients with HFpEF.
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http://dx.doi.org/10.1111/jgs.17004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8286810PMC
May 2021

High-sensitivity cardiac troponin T and the risk of heart failure in postmenopausal women of the ARIC Study.

Menopause 2021 01 4;28(3):284-291. Epub 2021 Jan 4.

Advanced Heart Failure and Transplant Cardiology, University of North Carolina, Chapel Hill, NC.

Objective: We investigated isolated and joint effects of early menopause (occurrence before 45 y of age) and high-sensitivity cardiac troponin T elevation (hs-cTnT ≥ 14 ng/L) on heart failure (HF) incidence in postmenopausal women.

Methods: We included 2,276 postmenopausal women, aged 67-90 years, with hs-cTnT measurements and without prevalent HF from the Atherosclerosis Risk in Communities study Visit 5 (2011-2013). Women were categorized according to early menopause and hs-cTnT group. Cox proportional hazards models were used for analysis.

Results: Over a median follow-up of 5.5 years, we observed 104 HF events. The incidence rates of HF were greater in women with hs-cTnT elevation when compared to those without hs-cTnT elevation. In unadjusted analysis, the hazard ratios for incident HF were threefold greater in women with hs-cTnT elevation, with or without early menopause, (3.03 [95% CI, 1.59-5.77]) and (3.29 [95% CI, 2.08-5.21]), respectively, but not significantly greater in women with early menopause without hs-cTnT elevation, when compared to women with neither early menopause nor hs-cTnT elevation at Visit 5. After adjusting for HF risk factors and NT-pro B-type natriuretic peptide, these associations were attenuated and became nonsignificant for women with hs-cTnT elevation, but became stronger and significant for women with early menopause without hs-cTnT elevation (2.39 [95% CI, 1.28-4.46]).

Conclusions: Irrespective of early menopause status, hs-cTnT elevation is associated with greater HF incidence but this association is partially explained by HF risk factors. Even in the absence of hs-cTnT elevation, early menopause is significantly associated with HF incidence after accounting for HF risk factors.
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http://dx.doi.org/10.1097/GME.0000000000001705DOI Listing
January 2021

Three new species of Gelechiidae (Lepidoptera) from Panama.

Zootaxa 2020 Dec 3;4890(3):zootaxa.4890.3.7. Epub 2020 Dec 3.

Universidad de Panamá, Vicerrectoría de Investigación y Postgrado. Doctorado en Ciencias Biológicas con énfasis en Entomología, Panama..

Aristotelia barriosi sp. nov. (Veraguas Province, Santa Fe NP), Agnippe tarakanovi sp. nov. (Herrera Province, Sarigua NP) and Chionodes sariguaensis sp. nov. (Herrera Province, Sarigua NP) are described from Panama. Adults and the genitalia of both sexes for all species and the habitats of two latter species are illustrated.
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http://dx.doi.org/10.11646/zootaxa.4890.3.7DOI Listing
December 2020

Prevalence and Prognostic Significance of Mitral Regurgitation in Acute Decompensated Heart Failure: The ARIC Study.

JACC Heart Fail 2021 03 9;9(3):179-189. Epub 2020 Dec 9.

Division of Cardiology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA. Electronic address:

Objectives: This study investigates the prevalence and prognostic significance of mitral regurgitation (MR) in acute decompensated heart failure (ADHF) patients.

Background: Few studies characterize the burden of MR in heart failure.

Methods: The ARIC (Atherosclerosis Risk In Communities) study surveilled ADHF hospitalizations for residents ≥55 years of age in 4 U.S. communities. ADHF cases were stratified by left ventricular ejection fraction (LVEF): <50% and ≥50%. Odds of moderate or severe MR in patients with varying sex and race, and odds of 1-year mortality in those with higher MR severity were estimated using multivariable logistic regression.

Results: From 2005 to 2014, there were 17,931 weighted ADHF hospitalizations of which 49.2% had an LVEF <50% and 50.8% an LVEF ≥50%. Moderate or severe MR prevalence was 44.5% in those with an LVEF <50% and 27.5% in those with an LVEF ≥50%. Moderate or severe MR was more likely in females than males regardless of LVEF; LVEF <50% (odds ratio [OR]: 1.21 [95% confidence interval (CI): 1.11 to 1.33]), LVEF ≥50% (OR: 1.52 [95% CI: 1.36 to 1.69]). Among hospitalizations with an LVEF ≥50%, moderate or severe MR was less likely in blacks than whites (OR: 0.72 [95% CI: 0.64 to 0.82]). Higher MR severity was independently associated with increased 1-year mortality in those with an LVEF <50% (OR: 1.30 [95% CI: 1.16 to 1.45]).

Conclusions: Patients with ADHF have a significant MR burden that varies with sex and race. In ADHF patients with an LVEF <50%, higher MR severity is associated with excess 1-year mortality.
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http://dx.doi.org/10.1016/j.jchf.2020.09.015DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8075289PMC
March 2021

Association of Midlife Cardiovascular Risk Factors With the Risk of Heart Failure Subtypes Later in Life.

J Card Fail 2021 04 22;27(4):435-444. Epub 2020 Nov 22.

Columbia University Irving Medical Center, Columbia University, New York, New York. Electronic address:

Background: Independent associations between cardiovascular risk factor exposures during midlife and later life development of heart failure (HF) with preserved ejection fraction (HFpEF) versus reduced EF (HFrEF) have not been previously studied.

Methods: We pooled data from 4 US cohort studies (Atherosclerosis Risk in Communities, Cardiovascular Health, Health , Aging and Body Composition, and Multi-Ethnic Study of Atherosclerosis) and imputed annual risk factor trajectories for body mass index, systolic and diastolic blood pressure, low-density lipoprotein and high-density lipoprotein cholesterol, and glucose starting from age 40 years. Time-weighted average exposures to each risk factor during midlife and later life were calculated and analyzed for associations with the development of HFpEF or HFrEF.

Results: A total of 23,861 participants were included (mean age at first in-person visit, 61.8 ±1 0.2 years; 56.6% female). During a median follow-up of 12 years, there were 3666 incident HF events, of which 51% had EF measured, including 934 with HFpEF and 739 with HFrEF. A high midlife systolic blood pressure and low midlife high-density lipoprotein cholesterol were associated with HFrEF, and a high midlife body mass index, systolic blood pressure, pulse pressure, and glucose were associated with HFpEF. After adjusting for later life exposures, only midlife pulse pressure remained independently associated with HFpEF.

Conclusions: Midlife exposure to cardiovascular risk factors are differentially associated with HFrEF and HFpEF later in life. Having a higher pulse pressure during midlife is associated with a greater risk for HFpEF but not HFrEF, independent of later life exposures.
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http://dx.doi.org/10.1016/j.cardfail.2020.11.008DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7987686PMC
April 2021

Recurrent Admissions for Acute Decompensated Heart Failure Among Patients With and Without Peripheral Artery Disease: The ARIC Study.

J Am Heart Assoc 2020 11 26;9(21):e017174. Epub 2020 Oct 26.

Joint Department of Biomedical Engineering University of North Carolina and North Carolina State University Chapel Hill NC.

Background Peripheral artery disease (PAD) is both a common comorbidity and a contributing factor to heart failure. Whether PAD is associated with hospitalization for recurrent decompensation among patients with established heart failure is uncertain. Methods and Results Since 2005, the ARIC (Atherosclerosis Risk in Communities) study has conducted active surveillance of hospitalized acute decompensated heart failure (ADHF), with events verified by physician review. From 2005 to 2016, 1481 patients were hospitalized with ADHF and discharged alive (mean age, 78 years; 69% White). Of these, 207 (14%) had diagnosis of PAD. Those with PAD were more often men (55% versus 44%) and smokers (17% versus 8%), with a greater prevalence of coronary artery disease (72% versus 52%). Patients with PAD had an increased risk of at least 1 ADHF readmission, both within 30 days (11% versus 7%) and 1 year (39% versus 28%) of discharge from the index hospitalization. After adjustments, PAD was associated with twice the hazard of ADHF readmission within 30 days (HR, 2.02; 95% CI, 1.14-3.60) and a 60% higher hazard of ADHF readmission within 1 year (HR, 1.60; 95% CI, 1.25-2.05). The 1-year hazard of ADHF readmission associated with PAD was stronger with heart failure with reduced ejection fraction (HR, 2.01; 95% CI, 1.29-3.13) than preserved ejection fraction (HR, 1.04; 95% CI, 0.69-1.56); for interaction=0.05. Conclusions Patients with ADHF and concomitant PAD have a higher likelihood of ADHF readmission. Strategies to prevent ADHF readmissions in this high-risk group are warranted.
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http://dx.doi.org/10.1161/JAHA.120.017174DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7763414PMC
November 2020

Predictors of Mortality by Sex and Race in Heart Failure With Preserved Ejection Fraction: ARIC Community Surveillance Study.

J Am Heart Assoc 2020 10 14;9(19):e014669. Epub 2020 Sep 14.

Duke University School of Medicine Durham NC.

Background Heart failure with preserved ejection fraction (HFpEF) accounts for half of heart failure hospitalizations, with limited data on predictors of mortality by sex and race. We evaluated for differences in predictors of all-cause mortality by sex and race among hospitalized patients with HFpEF in the ARIC (Atherosclerosis Risk in Communities) Community Surveillance Study. Methods and Results Adjudicated HFpEF hospitalization events from 2005 to 2013 were analyzed from the ARIC Community Surveillance Study, comprising 4 US communities. Comparisons between clinical characteristics and mortality at 1 year were made by sex and race. Of 4335 adjudicated acute decompensated heart failure cases, 1892 cases (weighted n=8987) were categorized as HFpEF. Men had an increased risk of 1-year mortality compared with women in adjusted analysis (hazard ratio [HR], 1.27; 95% CI, 1.06-1.52 [=0.01]). Black participants had lower mortality compared with White participants in unadjusted and adjusted analyses (HR, 0.79; 95% CI, 0.64-0.97 [=0.02]). Age, heart rate, worsening renal function, and low hemoglobin were associated with increased mortality in all subgroups. Higher body mass index was associated with improved survival in men, with borderline interaction by sex. Higher blood pressure was associated with improved survival among all groups, with significant interaction by race. Conclusions In a diverse HFpEF population, men had worse survival compared with women, and Black participants had improved survival compared with White participants. Age, heart rate, and worsening renal function were associated with increased mortality across all subgroups; high blood pressure was associated with decreased mortality with interaction by race. These insights into sex- and race-based differences in predictors of mortality may help strategize targeted management of HFpEF.
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http://dx.doi.org/10.1161/JAHA.119.014669DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7792380PMC
October 2020

Factors Associated With Cognitive Impairment in Heart Failure With Preserved Ejection Fraction.

J Cardiovasc Nurs 2020 Jul 1. Epub 2020 Jul 1.

Kenneth M. Faulkner, PhD, RN, ANP Clinical Associate Professor, Stony Brook University School of Nursing, New York. Victoria Vaughan Dickson, PhD, CRNP, FAHA, FHFSA, FAAN Director, Pless Center for Research, New York University Rory Meyers College of Nursing, New York, NY. Jason Fletcher, PhD Senior Biostatistician, New York University Rory Meyers College of Nursing, New York. Stuart D. Katz, MD Director, New York University Langone Health Heart Failure Program, New York. Patricia P. Chang, MD, MHS Director, Heart Failure and Transplant Program, University of North Carolina School of Medicine, Chapel Hill. Rebecca F. Gottesman, MD, PhD Professor of Neurology and Epidemiology, School of Medicine, Johns Hopkins University, Baltimore, Maryland. Lucy S. Witt, MD, MPH Professor, Emory University Department of Hospital Medicine, Atlanta, Georgia. Amil M. Shah, MD Co-director, Cardiac Imaging Core Laboratory, Brigham and Women's Hospital, Boston, Massachusetts. Gail D'Eramo Melkus, EdD, C-NP, FAAN Associate Dean for Research, New York University Rory Meyers College of Nursing, New York.

Background: Cognitive impairment is prevalent in heart failure and is associated with higher mortality rates. The mechanism behind cognitive impairment in heart failure with preserved ejection fraction (HFpEF) has not been established.

Objective: The aim of this study was to evaluate associations between abnormal cardiac hemodynamics and cognitive impairment in individuals with HFpEF.

Methods: A secondary analysis of Atherosclerosis Risk in Communities (Atherosclerosis Risk in Communities) study data was performed. Participants free of stroke or dementia who completed in-person assessments at visit 5 were included. Neurocognitive test scores among participants with HFpEF, heart failure with reduced ejection fraction (HFrEF), and no heart failure were compared. Sociodemographics, comorbid illnesses, medications, and echocardiographic measures of cardiac function that demonstrated significant (P < .10) bivariate associations with neurocognitive test scores were included in multivariate models to identify predictors of neurocognitive test scores among those with HFpEF. Multiple imputation by chained equations was used to account for missing values.

Results: Scores on tests of attention, language, executive function, and global cognitive function were worse among individuals with HFpEF than those with no heart failure. Neurocognitive test scores were not significantly different among participants with HFpEF and HFrEF. Worse diastolic function was weakly associated with worse performance in memory, attention, and language. Higher cardiac index was associated with worse performance on 1 test of attention.

Conclusions: Cognitive impairment is prevalent in HFpEF and affects several cognitive domains. The current study supports the importance of cognitive screening in patients with heart failure. An association between abnormal cardiac hemodynamics and cognitive impairment was observed, but other factors are likely involved.
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http://dx.doi.org/10.1097/JCN.0000000000000711DOI Listing
July 2020

Temporal Trends in Prevalence and Prognostic Implications of Comorbidities Among Patients With Acute Decompensated Heart Failure: The ARIC Study Community Surveillance.

Circulation 2020 07 3;142(3):230-243. Epub 2020 Jun 3.

Joint Department of Biomedical Engineering, University of North Carolina and North Carolina State University, Chapel Hill (M.C.C.).

Background: Patients with heart failure (HF) have multiple coexisting comorbidities. The temporal trends in the burden of comorbidities and associated risk of mortality among patients with HF with preserved ejection fraction (HFpEF) and HF with reduced ejection fraction (HFrEF) are not well established.

Methods: HF-related hospitalizations were sampled by stratified design from 4 US areas in 2005 to 2014 by the community surveillance component of the ARIC study (Atherosclerosis Risk in Communities). Acute decompensated HF was classified by standardized physician review and a previously validated algorithm. An ejection fraction <50% was considered HFrEF. A total of 15 comorbidities were abstracted from the medical record. Mortality outcomes were ascertained for up to 1-year postadmission by linking hospital records with death files.

Results: A total of 5460 hospitalizations (24 937 weighted hospitalizations) classified as acute decompensated HF had available ejection fraction data (53% female, 68% white, 53% HFrEF, 47% HFpEF). The average number of comorbidities was higher for patients with HFpEF versus HFrEF, both for women (5.53 versus 4.94; <0.0001) and men (5.20 versus 4.82; <0.0001). There was a significant temporal increase in the overall burden of comorbidities, both for patients with HFpEF (women: 5.17 in 2005-2009 to 5.87 in 2010-2013; men: 4.94 in 2005-2009 and 5.45 in 2010-2013) and HFrEF (women: 4.78 in 2005-2009 to 5.14 in 2010-2013; men: 4.62 in 2005-2009 and 5.06 in 2010-2013; -trend<0.0001 for all). Higher comorbidity burden was significantly associated with higher adjusted risk of 1-year mortality, with a stronger association noted for HFpEF (hazard ratio [HR] per 1 higher comorbidity, 1.19 [95% CI, 1.14-1.25] versus HFrEF (HR, 1.10 [95% CI, 1.05-1.14]; for interaction by HF type=0.02). The associated mortality risk per 1 higher comorbidity also increased significantly over time for patients with HFpEF and HFrEF, as well ( for interaction with time=0.002 and 0.02, respectively) Conclusions: The burden of comorbidities among hospitalized patients with acute decompensated HFpEF and HFrEF has increased over time, as has its associated mortality risk. Higher burden of comorbidities is associated with higher risk of mortality, with a stronger association noted among patients with HFpEF versus HFrEF.
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http://dx.doi.org/10.1161/CIRCULATIONAHA.120.047019DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7654711PMC
July 2020

Mitochondrial DNA Copy Number and Incident Heart Failure: The Atherosclerosis Risk in Communities (ARIC) Study.

Circulation 2020 06 1;141(22):1823-1825. Epub 2020 Jun 1.

Departments of Epidemiology and Medicine, and Welch Center for Prevention, Epidemiology, and Clinical Research, Bloomberg School of Public Health (Y.S.H., D.Z., K.M., E.G.), Johns Hopkins University, Baltimore, MD.

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http://dx.doi.org/10.1161/CIRCULATIONAHA.120.046001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7295435PMC
June 2020

Cardiac Amyloidosis: Evolving Diagnosis and Management: A Scientific Statement From the American Heart Association.

Circulation 2020 07 1;142(1):e7-e22. Epub 2020 Jun 1.

Transthyretin amyloid cardiomyopathy (ATTR-CM) results in a restrictive cardiomyopathy caused by extracellular deposition of transthyretin, normally involved in the transportation of the hormone thyroxine and retinol-binding protein, in the myocardium. Enthusiasm about ATTR-CM has grown as a result of 3 simultaneous areas of advancement: Imaging techniques allow accurate noninvasive diagnosis of ATTR-CM without the need for confirmatory endomyocardial biopsies; observational studies indicate that the diagnosis of ATTR-CM may be underrecognized in a significant proportion of patients with heart failure; and on the basis of elucidation of the mechanisms of amyloid formation, therapies are now approved for treatment of ATTR-CM. Because therapy for ATTR-CM may be most effective when administered before significant cardiac dysfunction, early identification of affected individuals with readily available noninvasive tests is essential. This scientific statement is intended to guide clinical practice and to facilitate management conformity by covering current diagnostic and treatment strategies, as well as unmet needs and areas of active investigation in ATTR-CM.
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http://dx.doi.org/10.1161/CIR.0000000000000792DOI Listing
July 2020

Incident Heart Failure and Long-Term Risk for Venous Thromboembolism.

J Am Coll Cardiol 2020 01;75(2):148-158

Division of Epidemiology and Community Health, University of Minnesota School of Public Health, Minneapolis, Minnesota.

Background: Heart failure (HF) hospitalization places patients at increased short-term risk for venous thromboembolism (VTE). Long-term risk for VTE associated with incident HF, HF subtypes, or structural heart disease is unknown.

Objectives: In the ARIC (Atherosclerosis Risk In Communities) cohort, VTE risk associated with incident HF, HF subtypes, and abnormal echocardiographic measures in the absence of clinical HF was assessed.

Methods: During follow-up, ARIC identified incident HF and subcategorized HF with preserved ejection fraction or reduced ejection fraction. At the fifth clinical examination, echocardiography was performed. Physicians adjudicated incident VTE using hospital records. Adjusted Cox proportional hazards models were used to evaluate the association between HF or echocardiographic exposures and VTE.

Results: Over a mean of 22 years in 13,728 subjects, of whom 2,696 (20%) developed incident HF, 729 subsequent VTE events were identified. HF was associated with increased long-term risk for VTE (adjusted hazard ratio: 3.13; 95% confidence interval: 2.58 to 3.80). In 7,588 subjects followed for a mean of 10 years, the risk for VTE was similar for HF with preserved ejection fraction (adjusted hazard ratio: 4.71; 95% CI: 2.94 to 7.52) and HF with reduced ejection fraction (adjusted hazard ratio: 5.53; 95% confidence interval: 3.42 to 8.94). In 5,438 subjects without HF followed for a mean of 3.5 years, left ventricular relative wall thickness and mean left ventricular wall thickness were independent predictors of VTE.

Conclusions: In this prospective population-based study, incident hospitalized HF (including both heart failure with preserved ejection fraction and reduced ejection fraction), as well as echocardiographic indicators of left ventricular remodeling, were associated with greatly increased risk for VTE, which persisted through long-term follow-up. Evidence-based strategies to prevent long-term VTE in patients with HF, beyond time of hospitalization, are needed.
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http://dx.doi.org/10.1016/j.jacc.2019.10.058DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7262575PMC
January 2020

Prospective study of plasma high molecular weight kininogen and prekallikrein and incidence of coronary heart disease, ischemic stroke and heart failure.

Thromb Res 2019 Oct 22;182:89-94. Epub 2019 Aug 22.

Department of Pathology and Laboratory Medicine, University of Vermont College of Medicine, Main Pavilion, 111 Colchester Ave, Burlington, VT 05401, United States; Department of Medicine, University of Vermont College of Medicine, Main Pavilion, 111 Colchester Ave, Burlington, VT 05401, United States. Electronic address:

Introduction: High molecular weight kininogen (HK) and prekallikrein (PK) are proteins in the kallikrein/kinin system of the coagulation cascade. They play an important role in the contact activation system of the intrinsic coagulation pathway, renin-angiotensin activation, and inflammation. Hence these proteins have been posited to affect the occurrence of cardiovascular events and thus to be potential therapeutic targets. Previous case-control studies have provided inconsistent evidence for an association of HK and PK with cardiovascular disease.

Methods: In the prospective population-based Atherosclerosis Risk in Communities(ARIC) Study, we used Cox proportional hazards regression models to investigate the association in 4195 middle-aged adults of plasma HK and PK concentrations in 1993-95 (linearly and in quartiles) with incident coronary heart disease, ischemic stroke, and heart failure through 2016.

Results: Over a mean of 18 years follow-up, we identified incident cardiovascular events (coronary heart disease and ischemic stroke) in 618 participants and heart failure in 667. We observed no significant relation between HK or PK and cardiovascular disease or heart failure, before and after adjusting for several potential confounding variables.

Conclusions: We found no compelling evidence to support an association of plasma HK or PK concentrations with incident CHD, ischemic stroke, or heart failure.
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http://dx.doi.org/10.1016/j.thromres.2019.08.009DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6825898PMC
October 2019

In-Hospital and Postdischarge Mortality Among Patients With Acute Decompensated Heart Failure Hospitalizations Ending on the Weekend Versus Weekday: The ARIC Study Community Surveillance.

J Am Heart Assoc 2019 08 19;8(15):e011631. Epub 2019 Jul 19.

University of North Carolina School of Medicine Chapel Hill NC.

Background Hospital staffing is usually reduced on weekends, potentially impacting inpatient care and postdischarge coordination of care for patients with acute decompensated heart failure (ADHF). However, investigations of in-hospital mortality on the weekend versus weekday, and post-hospital outcomes of weekend versus weekday discharge are scarce. Methods and Results Hospitalizations for ADHF were sampled by stratified design from 4 US areas by the Community Surveillance component of the ARIC (Atherosclerosis Risk in Communities) study. ADHF was classified by a standardized computer algorithm and physician review of the medical records. Discharges or deaths on Saturday, Sunday, or national holidays were considered to occur on the "weekend." In-hospital mortality was compared between hospitalizations ending on a weekend versus weekday. Post-hospital (28-day) mortality was compared among patients discharged alive on a weekend versus weekday. From 2005 to 2014, 39 699 weighted ADHF hospitalizations were identified (19% terminating on a weekend). Demographics, comorbidities, length of stay, and guideline-directed therapies were similar for patients with hospitalizations ending on a weekend versus weekday. In-hospital death doubled on the weekend compared with weekday (12% versus 6%) and was not attenuated by adjustment for potential confounders (odds ratio, 2.37; 95% CI, 1.93-2.91). There was no association between weekend discharge and 28-day mortality among patients discharged alive. Conclusions The risk of in-hospital death among patients admitted with ADHF appears to be doubled on the weekends when hospital staffing is usually reduced. However, among patients discharged alive, hospital discharge on a weekend is not adversely associated with mortality.
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http://dx.doi.org/10.1161/JAHA.118.011631DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6761634PMC
August 2019

The Last Year in Patients With Heart Failure: More Than Just Heart.

Authors:
Patricia P Chang

JACC Heart Fail 2019 07;7(7):571-573

Division of Cardiology, Department of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina. Electronic address:

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http://dx.doi.org/10.1016/j.jchf.2019.04.016DOI Listing
July 2019

A multi-component, family-focused and literacy-sensitive intervention to improve medication adherence in patients with heart failure-A randomized controlled trial.

Heart Lung 2019 Nov - Dec;48(6):507-514. Epub 2019 Jun 7.

Division of General Medicine and Clinical Epidemiology, School of Medicine, University of North Carolina at Chapel Hill, NC, United States.

Background: Medication nonadherence is prevalent and links to serious outcomes (e.g., rehospitalization/death) in heart failure (HF) patients; therefore, an urgent need exists for an intervention to improve and sustain adherence after intervention completion.

Objectives: To test the efficacy of a multi-component, family-focused, literacy-sensitive (FamLit) intervention on medication adherence in HF patients.

Methods: Forty-three HF patients and their care partners were enrolled and randomized to receive FamLit or attention-only intervention, including an in-person session at baseline and bi-weekly phone boosters for 3 months. We measured medication adherence from baseline to 3-month post-intervention using the Medication Event Monitoring System.

Results: After 3-month intervention, intervention patients had significantly better medication adherence than control patients. At 6 months (3-months post-intervention), intervention effect on adherence was sustained in the FamLit intervention group, while adherence decreased in the control group.

Conclusion: Incorporating care partner support and providing an easy-to-understand intervention to patients-care partners may improve/sustain adherence.
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http://dx.doi.org/10.1016/j.hrtlng.2019.05.011DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6851458PMC
March 2020

Desensitization for sensitized patients awaiting heart transplant.

Curr Opin Organ Transplant 2019 06;24(3):233-238

Division of Cardiology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.

Purpose Of Review: This review summarizes contemporary desensitization strategies for patients awaiting cardiac transplantation in an era when specific management is still somewhat controversial.

Recent Findings: The number of sensitized patients awaiting heart transplantation is rising. Clinical assessment of antibody levels is mostly focused on human leukocyte antigen (HLA) antibodies. Sensitization to HLA antigens increases the risk of antibody medicated rejection and cardiac allograft vasculopathy after transplant, thus translates to reduced access to compatible donors and increased wait time to transplant. Desensitization therapy is commonly considered in listed patients with cPRA more than 50%, to either decrease the amount of circulating anti-HLA antibodies, reduce the antibody production, or a combination of both. Despite promising results on specific therapies (e.g., plasmapheresis, intravenous immunoglobulin, rituximab, bortezomib), there is a significant gap in knowledge on desensitization therapies in heart transplantation. Most data are from small observational studies and extrapolated from nonheart solid organ transplants.

Summary: Management of the sensitized patient awaiting heart transplant is individualized. Desensitization can facilitate negative cross-match and successful transplantation, but is associated with significant cost and potential adverse effects. The long-term outcomes of desensitization therapy remain to be determined, further emphasizing the importance of personalizing the treatment approach to each patient.
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http://dx.doi.org/10.1097/MOT.0000000000000639DOI Listing
June 2019

The modifying effects of social support on psychological outcomes in patients with heart failure.

Health Psychol 2019 Jun 18;38(6):502-508. Epub 2019 Apr 18.

Department of Psychiatry and Behavioral Sciences.

Objective: We examined the modifying effects of social support on depressive symptoms and health-related quality of life (QoL) in patients receiving coping skills training (CST).

Method: We considered the modifying effects of social support in the Coping Effectively with Heart Failure clinical trial, which randomized 179 heart failure (HF) patients to either 4 months of CST or usual care enhanced by HF education (HFE). CST involved training in specific coping techniques, whereas HFE involved education about HF self-management. Social support was assessed by the Enhancing Recovery in Coronary Heart Disease (ENRICHD) Social Support Inventory, QoL was assessed with the Kansas City Cardiomyopathy Questionnaire (KCCQ), and depression was assessed with the Beck Depression Inventory-II (BDI-II).

Results: Linear regression models revealed a significant Intervention Group × Baseline Social Support interaction for change in KCCQ total scores (p = .006) and BDI-II scores (p < .001). Participants with low social support assigned to the CST intervention showed large improvements in KCCQ scores (M = 11.2, 95% CI [5.7, 16.8]), whereas low-social-support patients assigned to the HFE controls showed no significant change (M = -0.8, 95% CI [-7.2, 5.6]). Similarly, BDI-II scores in participants with low social support in the CST group showed large reductions (M = -8.7, 95% CI [-11.3, -6.1]) compared with low-social-support HFE participants (M = -3.0, 95% CI [-6.0, -0.1]).

Conclusions: HF patients with low social support benefit substantially from telephone-based CST interventions. Targeting HF patients with low social support for behavioral interventions could prove to be a cost-effective strategy for improving QoL and reducing depression. (PsycINFO Database Record (c) 2019 APA, all rights reserved).
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http://dx.doi.org/10.1037/hea0000716DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6599535PMC
June 2019

Outcomes of decreasing versus increasing cardiac troponin in patients admitted with non-ST-segment elevation myocardial infarction: the Atherosclerosis Risk in Communities Surveillance Study.

Eur Heart J Acute Cardiovasc Care 2019 Apr 8:2048872619842983. Epub 2019 Apr 8.

1 Division of Cardiology, University of North Carolina at Chapel Hill, USA.

Background: The fourth universal definition of myocardial infarction requires an increase or decrease in cardiac troponin for the classification of non-ST-segment elevation myocardial infarction. We sought to determine whether the characteristics, management, and outcomes of patients admitted with non-ST-segment elevation myocardial infarction differ by the initial biomarker pattern.

Methods: We identified patients in the Atherosclerosis Risk in Communities Surveillance Study admitted with chest pain and an initially elevated cardiac troponin I, who presented within 12 hours of symptom onset and were classified with non-ST-segment elevation myocardial infarction. A change in cardiac troponin I required an absolute difference of at least 0.02 ng/mL on the first day of hospitalization, prior to invasive cardiac procedures.

Results: A total of 1926 hospitalizations met the inclusion criteria, with increasing cardiac troponin I more commonly observed (78%). Patients with decreasing cardiac troponin I were more often black (45% vs. 35%) and women (54% vs. 40%), and were less likely to receive non-aspirin antiplatelets (44% vs. 63%), lipid-lowering agents (62% vs. 80%), and invasive angiography (38% vs. 64%). Inhospital mortality was 3%, irrespective of the cardiac troponin I pattern. However, patients with decreasing cardiac troponin I had twice the 28-day mortality (12% vs. 5%; P=0.01). Fatalities within 28 days were more often attributable to non-cardiovascular causes in those with decreasing versus increasing cardiac troponin I (75% vs. 38%; P=0.01).

Conclusion: Patients presenting with chest pain and an initially elevated cardiac troponin I which subsequently decreases are less often managed by evidence-based therapies and have greater mortality, primarily driven by non-cardiovascular causes. Whether associations are attributable to type 2 myocardial infarction or a subacute presentation merits further investigation.
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http://dx.doi.org/10.1177/2048872619842983DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6854299PMC
April 2019

Sensitization in Heart Transplantation: Emerging Knowledge: A Scientific Statement From the American Heart Association.

Circulation 2019 03;139(12):e553-e578

Sensitization, defined as the presence of circulating antibodies, presents challenges for heart transplant recipients and physicians. When present, sensitization can limit a transplantation candidate's access to organs, prolong wait time, and, in some cases, exclude the candidate from heart transplantation altogether. The management of sensitization is not yet standardized, and current therapies have not yielded consistent results. Although current strategies involve antibody suppression and removal with intravenous immunoglobulin, plasmapheresis, and antibody therapy, newer strategies with more specific targets are being investigated.
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http://dx.doi.org/10.1161/CIR.0000000000000598DOI Listing
March 2019

Brachyonychia Associated with Acroosteolysis in Chronic Kidney Disease: How Phalange Shape Influences Nail Morphology.

Skin Appendage Disord 2018 Oct 24;4(4):264-267. Epub 2018 Apr 24.

Hospital General de Enfermedades IGSS, Ciudad de Guatemala, Guatemala.

Brachyonychia is a rare manifestation in patients with chronic kidney disease. Longtime disease, secondary hyperparathyroidism, and hemodialysis are common conditions among those who present it. We evaluated 8 cases who presented brachyonychia in the nephrology department and compared the clinical versus the radiographic findings, and evaluated how the tissue adjusts to the underlying bone structure, giving different forms to the nails. We conclude that brachyonychia and acroosteolysis in chronic kidney disease suggest long-term disease, secondary hyperparathyroidism, and hemodialysis, besides it being a good model on how the bony structure defines the soft tissue morphology.
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http://dx.doi.org/10.1159/000487898DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6219246PMC
October 2018

A case-control study of the risk factors for developing aspergillosis following cardiac transplant.

Clin Transplant 2018 09 20;32(9):e13367. Epub 2018 Aug 20.

UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.

Background: Invasive aspergillosis (IA) is a significant cause of morbidity and mortality following cardiac transplantation; however, data regarding the predictors of IA in this patient population are limited.

Methods: We conducted a case-control study to identify the risk factors for IA in patients who underwent cardiac transplantation at a single center from 1986 to 2008 (Cohort 1) and 2009 to 2015 (Cohort 2). Cases of IA were matched to two controls from the same year of transplantation, and data were collected from the date of cardiac transplantation to the date of documented Aspergillus infection for each case, or for an equivalent number of days for each control. Univariate and multivariate logistic regressions were used to identify independent predictors of IA in Cohort 1. After 2009, targeted antifungal prophylaxis with oral voriconazole was initiated in patients with risk factors for IA. The incidence of IA was compared pre- and postintervention.

Results: IA was identified in 23 of 189 (8.0%) patients within Cohort 1. Significant risk factors for IA on multivariate analysis included an increased number of pretransplant hospitalizations (OR 1.81, 95% CI 1.19-2.76) and posttransplant acute cellular allograft rejection (ACR) (OR 1.99, 95% 1.06-3.75). Following the implementation of targeted antifungal prophylaxis in 2009, IA was identified in 2 of 107 (2.0%) patients in Cohort 2.

Conclusions: Increased pretransplant hospitalizations and posttransplant ACR episodes represent significant risk factors for IA following cardiac transplant. Targeted antifungal prophylaxis in at-risk patients reduces the incidence of IA.
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http://dx.doi.org/10.1111/ctr.13367DOI Listing
September 2018

Heart Failure and Cognitive Impairment in the Atherosclerosis Risk in Communities (ARIC) Study.

J Gen Intern Med 2018 10 20;33(10):1721-1728. Epub 2018 Jul 20.

Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.

Background: Previous studies suggest that heart failure (HF) is an independent risk factor for cognitive decline. A better understanding of the relationship between HF, cognitive status, and cognitive decline in a community-based sample may help clinicians understand disease risk.

Objective: To examine whether persons with HF have a higher prevalence of cognitive impairment and whether persons developing HF have more rapid cognitive decline.

Design: This observational cohort study of American adults in the Atherosclerosis Risk in Communities (ARIC) study has two components: cross-sectional analysis examining the association between prevalent HF and cognition using multinomial logistic regression, and change over time analysis detailing the association between incident HF and change in cognition over 15 years.

Participants: Among visit 5 (2011-2013) participants (median age 75 years), 6495 had neurocognitive information available for cross-sectional analysis. Change over time analysis examined the 5414 participants who had cognitive scores and no prevalent HF at visit 4 (1996-1998).

Measurements: The primary outcome was cognitive status, classified as normal, mild cognitive impairment [MCI], and dementia on the basis of standardized cognitive tests (delayed word recall, word fluency, and digit symbol substitution). Cognitive change was examined over a 15-year period. Control variables included socio-demographic, vascular, and smoking/drinking measures.

Results: At visit 5, participants with HF had a higher prevalence of dementia (adjusted relative risk ratio [RRR] = 1.60 [95% CI 1.13, 2.25]) and MCI (RRR = 1.36 [1.12, 1.64]) than those without HF. A decline in cognition between visits 4 and 5 was - 0.07 standard deviation units [- 0.13, - 0.01] greater among persons who developed HF compared to those who did not. Results did not differ by ejection fraction.

Conclusion: HF is associated with neurocognitive dysfunction and decline independent of other co-morbid conditions. Further study is needed to determine the underlying pathophysiology.
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http://dx.doi.org/10.1007/s11606-018-4556-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6153245PMC
October 2018

The Approach to Antibodies After Heart Transplantation.

Curr Transplant Rep 2017 Sep 11;4(3):243-251. Epub 2017 Aug 11.

University of North Carolina at Chapel Hill, Division of Cardiology, Department of Medicine, Chapel Hill, NC.

A Purpose Of Review: This review summarizes recent data about antibodies after cardiac transplantation; what testing modalities are available and how frequently to employ them; as well as when treatment is necessary.

B Recent Findings: Technologies available for antibody detection have progressed over the past couple decades. New and preformed antibodies are associated with worse outcomes in transplant recipients.

C Summary: The frequency of screening for post-transplant antibodies and for antibody-mediated rejection (AMR) should be based on risk stratification. The presence of antibodies alone post-transplant does not constitute a diagnosis of AMR. Treatment of post-transplant antibodies and AMR should be made in conjunction with consideration of AMR grade and graft dysfunction. Future directions will involve improved detection methods and further understanding of non-HLA antibodies and de novo antibodies in the post-transplant population. Additionally, aggressive efforts are currently underway to provide more therapeutic options.
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http://dx.doi.org/10.1007/s40472-017-0162-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5939589PMC
September 2017
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