Decision making in advanced heart failure: bench, bedside, practice, and policy

Matlock, Daniel D.; Mcguire, W.C.; Magid, Molly; Allen, Larry A.

doi:10.1007/s10741-017-9631-6

Cited by 11 publications

(6 citation statements)

References 39 publications

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“…Within the syndrome of heart failure with reduced ejection fraction, there is a growing subgroup of patients who have worsening disease that is typified by signs and symptoms of hypotension and hypoperfusion . These patients, characterized as having stage D heart failure, are increasingly unable to tolerate neurohormonal blockade, and their options are limited to cardiac transplantation, ventricular assist devices, inotropic infusions, or hospice . The primary pathology in these patients is thought to be a decrease in cardiac contractility and the development of positive inotropes has been aimed at correcting this defect: almost every inotropic agent that survived to clinical evaluation has shared a common therapeutic goal: to increase the amplitude of cytosolic calcium transients or sensitivity of the sarcomere, thus increasing the force of contraction.…”

Section: A Brief History Of Inotropic Agents and Their Impact On Surrmentioning

confidence: 99%

Why has positive inotropy failed in chronic heart failure? Lessons from prior inotrope trials

Ahmad

Miller

McCullough

et al. 2019

European J of Heart Fail

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Current pharmacological therapies for heart failure with reduced ejection fraction are largely either repurposed anti‐hypertensives that blunt overactivation of the neurohormonal system or diuretics that decrease congestion. However, they do not address the symptoms of heart failure that result from reductions in cardiac output and reserve. Over the last few decades, numerous attempts have been made to develop and test positive cardiac inotropes that improve cardiac haemodynamics. However, definitive clinical trials have failed to show a survival benefit. As a result, no positive inotrope is currently approved for long‐term use in heart failure. The focus of this state‐of‐the‐art review is to revisit prior clinical trials and to understand the causes for their findings. Using the learnings from those experiences, we propose a framework for future trials of such agents that maximizes their potential for success. This includes enriching the trials with patients who are most likely to derive benefit, using biomarkers and imaging in trial design and execution, evaluating efficacy based on a wider range of intermediate phenotypes, and collecting detailed data on functional status and quality of life. With a rapidly growing population of patients with advanced heart failure, the epidemiologic insignificance of heart transplantation as a therapeutic intervention, and both the cost and morbidity associated with ventricular assist devices, there is an enormous potential for positive inotropic therapies to impact the outcomes that matter most to patients.

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Section: A Brief History Of Inotropic Agents and Their Impact On Surrmentioning

confidence: 99%

Why has positive inotropy failed in chronic heart failure? Lessons from prior inotrope trials

Ahmad

Miller

McCullough

et al. 2019

European J of Heart Fail

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“…Few studies evaluated the symptoms, clinical signs, shared decision-making, [ 30 , 31 ], and diagnostic procedures [ 32 ] to optimize patient care and heart failure outcomes. Moreover, a study by Pisa et al [ 33 ] used conjoint analysis to assess patients’ treatment preferences. However, no existing study incorporated conjoint analysis in assessing the clinical decision-making among physicians regarding heart failure based on symptoms, clinical signs, and biochemical markers.…”

Section: Discussionmentioning

confidence: 99%

Clinical Decision-Making for Heart Failure in Kosovo: A Conjoint Analysis

Hoxha

Guda²,

Hoti³

et al. 2022

IJERPH

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Background: Heart failure represents a life-threatening progressive condition. Early diagnosis and adherence to clinical guidelines are associated with improved outcomes for patients with heart failure. However, adherence to clinical guidelines remains limited in Kosovo. Objective: To assess the clinical decision-making related to heart failure diagnosis by evaluating clinicians’ preferences for clinical attributes. Method: Conjoint analysis with 33 clinical scenarios with physicians employed in public hospitals in Kosovo. Setting: Two public hospitals in Kosovo that benefited from quality improvement intervention. Participants: 14 physicians (internists and cardiologists) in two hospitals in Kosovo. Outcome measures: The primary outcome was the overall effect of clinical attributes on the decision for heart failure diagnosis. Results: When considering clinical signs, the likelihood of a heart failure diagnosis increased for ages between 60 to 69 years old (RRR, 1.88; CI 95%, 1.05–3.34) and a stable heart rate (RRR, 1.93; CI 95%, 1.05–3.55) and decreased for the presence of edema (RRR, 0.23; CI 95%, 0.15–0.36), orthopnea (RRR, 0.31; CI 95%, 0.20–0.48), and unusual fatigue (RRR, 0.61; CI 95%, 0.39–0.94). When considering clinical examination findings, the likelihood for heart failure diagnosis decreased for high jugular venous pressure (RRR, 0.49; CI 95%, 0.32–0.76), pleural effusion (RRR, 0.35; CI 95%, 0.23–0.54), hearing third heart sound, (RRR, 0.50; CI 95%, 0.33–0.77), heart murmur (RRR, 0.57; CI 95%, 0.37–0.88), troponin levels (RRR, 0.59; CI 95%, 0.38–0.91), and NTproBNP levels (RRR, 0.36; CI 95%, 0.24–0.56). Conclusions: We often found odd and wide variations of clinical signs and examination results influencing the decision to diagnose a person with heart failure. It will be important to explore and understand these results better. The study findings are important for existing quality improvement support efforts and contribute to the standardization of clinical decision-making in the public hospitals in the country. This experience and this study can provide valuable impetus for further examination of these efforts and informing policy and development efforts in the standardization of care in the country.

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“…Patients with advanced HF are transferred to another hospital for advanced medical treatment such as LVAD implantation and HTx based on the judgment that medical treatment at the current hospital is difficult [11] . Although there are some recommendations regarding patient transfer [12] , [13] , there are restrictions due to various disparities; problems such as regional characteristics of medical distribution make such transfers complicated [14] , and it is extremely difficult to make an appropriate judgment in the setting in which there is no clear judgment standard. Furthermore, the lack of understanding of the actual conditions of transfer itself and the clinical course after transfer, such as the transfer procedure and adverse effect due to transfer, may raise the hurdle for the judgment at the transfer source.…”

Section: Discussionmentioning

confidence: 99%