Robert J Mentz

Duke University Medical Center, Durham, North Carolina, United States

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Publications (72)373.08 Total impact

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    ABSTRACT: There are more than 1 million primary hospitalizations for heart failure (HF) annually in the USA alone, and post-discharge outcomes remain persistently poor despite available therapies and quality improvement initiatives. Recent international randomized clinical trials in hospitalized HF have repeatedly failed to improve this post-discharge event rate. A potential reason for this persistent lack of clinical trial success that has not previously received significant attention relates to site selection and the generally low level of patient enrollment from the USA. Only ~5 % of US hospitals participate in clinical trials, and in four recent randomized trials of hospitalized HF, only one-third of patients were enrolled in North America. This poor participation among US centers has necessitated disproportionate enrollment from non-US sites. Regional variations in HF patient characteristics and clinical outcomes are well documented, and a lack of US patient representation in clinical trials limits the generalizability of results and presents obstacles for US regulatory agency approval. There are multiple impediments to successful US enrollment including a lack of incentive for investigators and institutions, the relative value unit-based compensation system, poor institutional framework for identification of appropriate patients, and increasing liability to conduct trials. In this manuscript, we specifically identify barriers to successful hospitalized HF clinical trial participation in the USA and suggest possible solutions.
    Heart Failure Reviews 02/2015; DOI:10.1007/s10741-015-9473-z · 3.99 Impact Factor
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    ABSTRACT: The prevalence of patients with concomitant heart failure (HF) and diabetes mellitus (DM) continues to increase with the general aging of the population. In patients with chronic HF, prevalence of DM is 24% compared with 40% in those hospitalized with worsening HF. Patients with concomitant HF and DM have diverse pathophysiologic, metabolic, and neurohormonal abnormalities that potentially contribute to worse outcomes than those without comorbid DM. In addition, although stable HF outpatients with DM show responses that are similar to those of patients without DM undergoing evidence-based therapies, it is unclear whether hospitalized HF patients with DM will respond similarly to novel investigational therapies. These data support the need to re-evaluate the epidemiology, pathophysiology, and therapy of HF patients with concomitant DM. This paper discusses the role of DM in HF patients and underscores the potential need for the development of targeted therapies. Copyright © 2015 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.
    02/2015; 3(2):136-145. DOI:10.1016/j.jchf.2014.08.004
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    ABSTRACT: The health and economic burden of heart failure is significant and continues to grow each year. Loop diuretics are an integral part of symptom management in heart failure. Furosemide is used disproportionately compared with other loop diuretics, and there is currently no guidance for physicians regarding which agent to choose. However, there exist pharmacologic differences as well as other mechanistic differences that appear to favor torsemide use over furosemide. Compared with furosemide, torsemide improves surrogate markers of heart failure severity such as left ventricular function, plasma brain natriuretic peptide levels, and New York Heart Association functional class and may also reduce hospitalizations, readmissions, and mortality. Data suggest that these benefits could be mediated through torsemide's ability to positively affect the renin-angiotensin-aldosterone system. Specifically, torsemide has been shown to inhibit aldosterone secretion, synthesis, and receptor binding in vitro, as well as decrease transcardiac extraction of aldosterone, myocardial collagen production, and cardiac fibrosis in patients with heart failure. We identified pertinent literature using keyword MEDLINE searches and cross-referencing prior bibliographies. We summarize the available data suggesting potential benefits with torsemide over furosemide, and call attention to the need for a reappraisal of diuretic use in heart failure patients and also for a well-powered, randomized control trial assessing torsemide versus furosemide use. Copyright © 2015 Elsevier Inc. All rights reserved.
    American Heart Journal 01/2015; 169(3). DOI:10.1016/j.ahj.2014.12.009 · 4.56 Impact Factor
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    ABSTRACT: -QRS prolongation is associated with adverse outcomes in mostly white populations, but its clinical significance is not well established for other groups. We investigated the association between QRS duration and mortality in African Americans. -We analyzed data from 5146 African Americans in the Jackson Heart Study stratified by QRS duration on baseline 12-lead electrocardiogram. We defined QRS prolongation as QRS ≥ 100 msec. We assessed the association between QRS duration and all-cause mortality using Cox proportional hazards models, and reported the cumulative incidence of heart failure (HF) hospitalization. We identified factors associated with the development of QRS prolongation in patients with normal baseline QRS. At baseline, 30% (n = 1528) of participants had QRS prolongation. The cumulative incidences of mortality and HF hospitalization were greater with versus without baseline QRS prolongation: 12.6% (95% CI, 11.0-14.4) vs. 7.1% (95% CI, 6.3-8.0) and 8.2% (95% CI, 6.9-9.7) vs. 4.4% (95% CI, 3.7-5.1), respectively. After risk adjustment, QRS prolongation was associated with increased mortality (HR, 1.27; 95% CI, 1.03-1.56; P = .02). There was a linear relationship between QRS duration and mortality (HR per 10 msec increase, 1.06; 95% CI, 1.01-1.12). Older age, male sex, prior myocardial infarction, lower ejection fraction, left ventricular hypertrophy, and left ventricular dilatation were associated with the development of QRS prolongation. -QRS prolongation in African Americans was associated with increased mortality and HF hospitalization. Factors associated with developing QRS prolongation included age, male sex, prior myocardial infarction, and left ventricular structural abnormalities.
    Circulation Heart Failure 12/2014; 8(2). DOI:10.1161/CIRCHEARTFAILURE.114.001729 · 5.95 Impact Factor
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    ABSTRACT: Cardiac resynchronization therapy is beneficial in heart failure patients with LVEF ≤35% and electrical dyssynchrony. However, its effects among patients with less severe LV dysfunction have not been established. Recent post-hoc analyses of landmark CRT trials suggest that CRT benefit may be present in patients with LVEF >35% and is associated with improvement in cardiac reverse remodelling, all-cause mortality, and need for heart failure hospitalizations. This review summarizes the currently available literature regarding the potential impact of CRT in patients with more modest reductions in LVEF. © 2014 The Authors. European Journal of Heart Failure © 2014 European Society of Cardiology.
    European Journal of Heart Failure 12/2014; DOI:10.1002/ejhf.208 · 6.58 Impact Factor
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    ABSTRACT: Previous heart failure (HF) trials suggested that age influences patient characteristics and outcome; however, under-representation of elderly patients has limited characterization of this cohort. Whether standard prognostic variables have differential utility in various age groups is unclear. The PROTECT trial investigated 2033 patients (median age 72 years) with acute HF randomized to rolofylline or placebo. Patients were divided into five groups based on the quintiles of age: ≤59, 60-68, 69-74, 75-79, and ≥80 years. Baseline characteristics, medications, and outcomes (30-day death or cardiovascular/renal hospitalization, and death at 30 and 180 days) were explored. The prognostic utility of baseline characteristics for outcomes was investigated in the different groups and in those aged <80 years vs. ≥80 years. With increasing age, patients were more likely to be women with hypertension, AF, and higher EF. Increased age was associated with increased risk of 30- and 180-day outcomes, which persisted after multivariable adjustment (hazard ratio for 180-day death = 1.17; 95% confidence interval 1.11-1.24 for each 5-year increase). The prognostic utility of baseline characteristics such as previous HF hospitalization and serum sodium, systolic blood pressure, and NYHA class was attenuated in the elderly for the endpoint of 180-day mortality. An increase in albumin was associated with a greater reduction in risk in patients aged ≥80 years vs. <80 years. In a large trial of acute HF, there were differences in baseline characteristics and outcomes amongst patients of different ages. Standard prognostic variables exhibit different utility in elderly patients. © 2014 The Authors. European Journal of Heart Failure © 2014 European Society of Cardiology.
    European Journal of Heart Failure 11/2014; 17(1). DOI:10.1002/ejhf.207 · 6.58 Impact Factor
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    ABSTRACT: Heart failure patients are classified by ejection fraction (EF) into distinct groups: heart failure with preserved ejection fraction (HFpEF) or heart failure with reduced ejection fraction (HFrEF). Although patients with heart failure commonly have multiple comorbidities that complicate management and may adversely affect outcomes, their role in the HFpEF and HFrEF groups is not well-characterized. This review summarizes the role of noncardiac comorbidities in patients with HFpEF versus HFrEF, emphasizing prevalence, underlying pathophysiologic mechanisms, and outcomes. Pulmonary disease, diabetes mellitus, anemia, and obesity tend to be more prevalent in HFpEF patients, but renal disease and sleep-disordered breathing burdens are similar. These comorbidities similarly increase morbidity and mortality risk in HFpEF and HFrEF patients. Common pathophysiologic mechanisms include systemic and endomyocardial inflammation with fibrosis. We also discuss implications for clinical care and future HF clinical trial design. The basis for this review was discussions between scientists, clinical trialists, and regulatory representatives at the 10th Global CardioVascular Clinical Trialists Forum.
    Journal of the American College of Cardiology 11/2014; DOI:10.1016/j.jacc.2014.08.036 · 15.34 Impact Factor
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    ABSTRACT: The purpose of this study was to assess the relationship between biomarkers of renin-angiotensin-aldosterone system (RAAS) activation and decongestion strategies, worsening renal function, and clinical outcomes. High-dose diuretic therapy in patients with acute heart failure (AHF) is thought to activate the RAAS; and alternative decongestion strategies, such as ultrafiltration (UF), have been proposed to mitigate this RAAS activation. This study analyzed 427 AHF patients enrolled in the DOSE-AHF (Diuretic Optimization Strategies in Acute Heart Failure) and CARRESS-HF (Cardiorenal Rescue Study in Acute Decompensated Heart Failure) trials. We assessed the relationship between 2 markers of RAAS activation (plasma renin activity [PRA] and aldosterone) from baseline to 72 h and 96 h and decongestion strategy: high- versus low-dose and continuous infusion versus bolus furosemide for DOSE-AHF and UF versus stepped pharmacologic care for CARRESS-HF. We determined the relationships between RAAS biomarkers and 60-day outcomes. Patients with greater RAAS activation at baseline had lower blood pressures, lower serum sodium levels, and higher blood urea nitrogen (BUN) concentration. Continuous infusion furosemide and UF were associated with greater PRA increases (median: +1.66 vs. +0.66 ng/ml/h with continuous vs. bolus infusion, respectively, p = 0.021; +4.05 vs. +0.56 ng/ml/h with UF vs. stepped care, respectively, p = 0.014). There were no significant differences in RAAS biomarker changes with high- versus low-dose diuretic therapy (both: p > 0.5). Neither baseline log PRA nor log aldosterone was associated with increased death or HF hospitalization (hazard ratio [HR] for a doubling of 1.05; 95% confidence interval [CI]: 0.98 to 1.13; p = 0.18; and HR: 1.13; 95% CI: 0.99 to 1.28; p = 0.069, respectively). The change in RAAS biomarkers from baseline to 72 and 96 h was not associated with outcomes (both: p > 0.5). High-dose loop diuretic therapy did not result in RAAS activation greater than that with low-dose diuretic therapy. UF resulted in greater PRA increase than stepped pharmacologic care. Neither PRA nor aldosterone was significantly associated with short-term outcomes in this cohort. (Determining Optimal Dose and Duration of Diuretic Treatment in People With Acute Heart Failure [DOSE-AHF]; NCT00577135; Effectiveness of Ultrafiltration in Treating People With Acute Decompensated Heart Failure and Cardiorenal Syndrome [CARRESS]; NCT00608491). Copyright © 2014 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.
    10/2014; DOI:10.1016/j.jchf.2014.09.003
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    ABSTRACT: Hospitalization for heart failure (HF) is frequently related to dyspnea, yet associations among dyspnea severity, outcomes, and health care costs are unknown. The aim of this study was to describe the characteristics of patients hospitalized for acute HF by dyspnea severity and to examine associations among dyspnea severity, outcomes, and costs. Registry data for patients hospitalized for HF were linked with Medicare claims to evaluate dyspnea and outcomes in patients ≥65 years of age. We classified patients by patient-reported dyspnea severity at admission. Outcomes included length of stay, mortality 30 days after admission, days alive and out of the hospital, readmission, and Medicare payments 30 days after discharge. Of 48,616 patients with acute HF and dyspnea, 4,022 (8.3%) had dyspnea with moderate activity, 19,619 (40.3%) with minimal activity, and 24,975 (51.4%) at rest. Patients with dyspnea with minimal activity or at rest had greater co-morbidities, including renal insufficiency. Greater severity of baseline dyspnea was associated with mortality (moderate activity, 6.3%; minimal activity, 7.6%; at rest, 11.6%) and HF readmission (7.2%, 9.0%, and 9.4%). After multivariate adjustment, dyspnea at rest was associated with greater 30-day mortality and HF readmission, fewer days alive and out of the hospital, longer length of stay, and higher Medicare payments compared with dyspnea with moderate activity. In conclusion, dyspnea at rest on presentation was associated with greater mortality, readmission, length of stay, and health care costs in patients hospitalized with acute HF. Copyright © 2014 Elsevier Inc. All rights reserved.
    The American Journal of Cardiology 10/2014; DOI:10.1016/j.amjcard.2014.09.048 · 3.43 Impact Factor
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    ABSTRACT: Heart failure (HF) is a public health problem of global proportions afflicting more than 25 million patients worldwide. Despite stable or declining per capita hospitalization rates in the USA and several European countries, there are over one million hospitalizations for HF annually in the USA, with similar numbers in Europe, accounting for 6.5 million hospital days and the majority of the approximately $40 billion spent each year on HF-related care. Moreover, clinical trial data suggest that post-discharge survival and readmissions have largely remained unchanged. Thus, understanding geographic and ethnic variations in HF is essential to formulating public policy at the local, national, regional, and international levels and setting the agenda for basic, translational, and clinical research endeavors. This paper aims to describe regional and ethnic variations in patient characteristics, management, and outcomes in hospitalized HF.
    Current Heart Failure Reports 09/2014; DOI:10.1007/s11897-014-0221-9
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    ABSTRACT: We investigated the clinical profiles associated with serum uric acid (sUA) levels in a large cohort of patients hospitalized for worsening chronic heart failure with ejection fraction (EF) ≤40%, with specific focus on gender, race, and renal function based interactions. In 3,955 of 4,133 patients (96%) with baseline sUA data, clinical characteristics and outcomes were compared across sUA quartiles. The primary end points were all-cause mortality and a composite of cardiovascular mortality or heart failure hospitalization. Interaction analyses were performed for gender, race, and baseline renal function. Median follow-up was 9.9 months. Mean sUA was 9.1 ± 2.8 mg/dl and was higher in men than in women (9.3 ± 2.7 vs 8.7 ± 3.0 mg/dl, p <0.001) and in blacks than in whites (10.0 ± 2.7 vs 9.0 ± 2.8 mg/dl, p <0.001). Higher sUA was associated with lower systolic blood pressure and EF, higher natriuretic peptides, and more impaired renal function. After accounting for 24 baseline covariates, in patients with enrollment estimated glomerular filtration rate ≥30 ml/min/1.73 m(2), sUA was strongly associated with increased all-cause mortality (hazard ratio 1.44, 95% confidence interval 1.22 to 1.69, p <0.001) and the composite end point (hazard ratio 1.44, 95% confidence interval 1.26 to 1.64, p <0.001). However, in patients with estimated glomerular filtration rate <30 ml/min/1.73 m(2), sUA was not related with either end point (both p >0.4). Adjusted interaction analyses for gender, race, and admission allopurinol use were not significant. In conclusion, sUA is commonly elevated in patients hospitalized for worsening chronic heart failure and reduced EF, especially in men and blacks. The prognostic use of sUA differs by baseline renal function, suggesting different biologic and pathophysiologic significance of sUA among those with and without significant renal dysfunction.
    The American Journal of Cardiology 09/2014; 114(11). DOI:10.1016/j.amjcard.2014.09.008 · 3.43 Impact Factor
  • Journal of Cardiac Failure 08/2014; 20(8S):S95. DOI:10.1016/j.cardfail.2014.06.267 · 3.07 Impact Factor
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    ABSTRACT: Recent international phase III clinical trials of novel therapies for hospitalized heart failure (HHF) have failed to improve the unacceptably high post-discharge event rate. These large studies have demonstrated notable geographic and site-specific variation in patient profiles and enrollment. Possible contributors to the lack of success in HHF outcome trials include challenges in selecting clinical sites capable of 1) providing adequate numbers of appropriately selected patients and 2) properly executing the study protocol. We propose a “pre-trial” registry as a novel tool for improving the efficiency and quality of international HHF trials by focusing on the selection and cultivation of high quality sites. A pre-trial registry may help assess a site’s ability to achieve adequate enrollment of the target patient population, integrate protocol requirements into clinical workflow, and accomplish appropriate follow-up. While such a process would be associated with additional upfront resource investment, this appropriation may be modest in comparison to the downstream costs associated with maintenance of poorly performing sites, failed clinical trials, and the global health and economic burden of HHF. This review is based on discussions between scientists, clinical trialists, and regulatory representatives regarding methods for improving international HHF trials that took place at the US Food and Drug Administration (FDA) on January 12th 2012.
    American Heart Journal 08/2014; 168(2). DOI:10.1016/j.ahj.2014.05.009 · 4.56 Impact Factor
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    ABSTRACT: AimsLoop diuretics are a cornerstone of heart failure (HF) treatment, but data regarding diuretic dose adjustments after a HF hospitalization and the association with subsequent outcomes are limited. This study was therefore conducted to determine these factors.Methods and resultsWe analysed data from 6119 patients enrolled in ASCEND-HF, examining the association between loop diuretic use at the time of discharge, compared with admission, and the composite outcome of 30-day HF re-hospitalization or all-cause mortality. The majority of patients, 3921 (64%), were taking a loop diuretic on admission. At discharge, 3411 (56%) patients were prescribed higher doses compared with admission, including 1867 (31%) initiating daily outpatient diuretics; 1912 (31%) had no dose change and 795 (13%) were prescribed lower doses compared with admission. Initiation of an oral loop diuretic at discharge was independently associated with better 30-day outcomes compared with no dose change [adjusted odds ratio (OR) 0.51, 95% confidence interval (CI) 0.37–0.68]. However, for patients that were already established on a loop diuretic prior to admission, change in the dose at discharge was not associated with improved outcomes compared with no dose change (adjusted OR 0.92, 95% CI 0.79–1.07).Conclusions In a large multinational clinical trial, 56% of patients hospitalized with HF were either initiated on a daily loop diuretic at discharge or discharged on higher doses compared with admission. In patients established on diuretics prior to hospitalization, we found no association between changes to chronic doses at discharge and improved outcomes, whereas initiation of loop diuretic therapy was associated with better outcomes compared with no dose change.
    European Journal of Heart Failure 08/2014; 20(8S):S49. DOI:10.1016/j.cardfail.2014.06.140 · 6.58 Impact Factor
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    ABSTRACT: The progressive nature of heart failure (HF) coupled with high mortality and poor quality of life mandates greater attention to palliative care as a routine component of advanced HF management. Limited evidence exists from randomized, controlled trials supporting the use of interdisciplinary palliative care in HF. Methods The Palliative Care in Heart Failure trial (PAL-HF) is a prospective, controlled, unblinded, single-center study of an interdisciplinary palliative care intervention in 200 patients with advanced HF estimated to have a high likelihood of mortality or re-hospitalization in the ensuing 6 months. The 6-month PAL-HF intervention focuses on physical and psychosocial symptom relief, attention to spiritual concerns and advanced care planning. The primary endpoint is health-related quality of life measured by the Kansas City Cardiomyopathy Questionnaire and the Functional Assessment of Chronic Illness Therapy with Palliative Care Subscale score at 6 months. Secondary endpoints include changes in anxiety/depression, spiritual well-being, caregiver satisfaction, cost and resource utilization, and a composite of death, HF hospitalization and quality of life. Conclusions PAL-HF is a randomized, controlled clinical trial that will help evaluate the efficacy and cost-effectiveness of palliative care in advanced HF using a patient-centered outcome as well as clinical and economic endpoints.
    American Heart Journal 07/2014; 168(5). DOI:10.1016/j.ahj.2014.07.018 · 4.56 Impact Factor
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    ABSTRACT: Background-A subset of patients hospitalized with acute heart failure experiences worsening clinical status and requires escalation of therapy. Worsening heart failure is an end point in many clinical trials, but little is known about its prevalence in clinical practice and its associated outcomes. Methods and Results-We analyzed inpatient data from the Acute Decompensated Heart Failure National Registry linked to Medicare claims to examine the prevalence and outcomes of patients with worsening heart failure, defined as the need for escalation of therapy at least 12 hours after hospital presentation. We compared patients with worsening heart failure to patients with an uncomplicated hospital course and patients with a complicated presentation. Of 63 727 patients hospitalized with acute heart failure, 11% developed worsening heart failure. These patients had the highest observed rates of mortality, all-cause readmission, and Medicare payments at 30 days and 1 year after hospitalization (P < 0.001 for all comparisons). The adjusted hazards of 30-day mortality were 2.56 (99% CI, 2.34 to 2.80) compared with an uncomplicated course and 1.29 (99% CI, 1.17 to 1.42) compared with a complicated presentation. The adjusted cost ratios for postdischarge Medicare payments at 30 days were 1.35 (99% CI, 1.24 to 1.46) compared with an uncomplicated course and 1.11 (99% CI, 1.02 to 1.22) compared with a complicated presentation. Conclusions-In-hospital worsening heart failure was common and was associated with higher rates of mortality, all-cause readmission, and postdischarge Medicare payments. Prevention and treatment of in-hospital worsening heart failure represents an important goal for patients hospitalized with acute heart failure.
    Journal of the American Heart Association 06/2014; 3(4). DOI:10.1161/JAHA.114.001088
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    ABSTRACT: Despite the well-established benefits of mineralocorticoid receptor agonists (MRAs) in heart failure with reduced ejection fraction, safety concerns remain in patients with concomitant diabetes mellitus (DM) because of common renal and electrolyte abnormalities in this population. We analyzed all-cause mortality and composite cardiovascular mortality and HF hospitalization over a median 9.9 months among 1,998 patients in the placebo arm of the Efficacy of Vasopressin Antagonism in Heart Failure Outcome Study With Tolvaptan (EVEREST) trial by DM status and discharge MRA use. Of the 750 patients with DM, 59.2% were receiving MRAs compared with 62.5% in the non-DM patients. DM patients not receiving MRAs were older, more likely to be men, with an ischemic heart failure etiology and slightly worse renal function compared with those receiving MRAs. After adjustment for baseline risk factors, among DM patients, MRA use was not associated with either mortality (hazard ratio [HR] 0.93; 95% confidence interval [CI] 0.75 to 1.15) or the composite end point (HR 0.94; 95% CI 0.80 to 1.10). Similar findings were seen in non-DM patients (mortality [HR 1.01; 95% CI 0.84 to 1.22] or the composite end point [HR 0.98; 95% CI 0.85 to 1.13] [p >0.43 for DM interaction]). In conclusion, in-hospital initiation of MRA therapy was low (15% to 20%), and overall discharge MRA use was only 60% (with regional variation), regardless of DM status. There does not appear to be clear, clinically significant in-hospital hemodynamic or even renal differences between those on and off MRA. Discharge MRA use was not associated with postdischarge end points in patients hospitalized for worsening heart failure with reduced ejection fraction and co-morbid DM. DM does not appear to influence the effectiveness of MRA therapy.
    The American Journal of Cardiology 06/2014; 114(5). DOI:10.1016/j.amjcard.2014.05.064 · 3.43 Impact Factor
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    ABSTRACT: Heart failure is a syndrome with a pathophysiological basis that can be traced to dysfunction in several interconnected molecular pathways. Identification of biomarkers of heart failure that allow measurement of the disease on a molecular level has resulted in enthusiasm for their use in prognostication and selection of appropriate therapies. However, despite considerable amounts of information available on numerous biomarkers, inconsistent research methodologies and lack of clinical correlations have made bench-to-bedside translations rare and left the literature with countless publications of varied quality. There is a need for a systematic and collaborative approach aimed at definitively studying the clinical benefits of novel biomarkers. In this review, on the basis of input from academia, industry, and governmental agencies, we propose a systematized approach based on adherence to specific quality measures for studies looking to augment current prediction model or use biomarkers to tailor therapeutics. We suggest that study quality, rather than results, should determine publication and propose a system for grading biomarker studies. We outline the need for collaboration between clinical investigators and statisticians to introduce more advanced statistical methodologies into the field of biomarkers that would allow for data from a large number of variables to be distilled into clinically actionable information. Lastly, we propose the creation of a heart failure biomarker consortium that would allow for a comprehensive list of biomarkers to be concomitantly analyzed in a pooled sample of randomized clinical trials and hypotheses to be generated for testing in biomarker-guided trials. Such a consortium could collaborate in sharing samples to identify biomarkers, undertake meta-analyses on completed trials, and spearhead clinical trials to test the clinical utility of new biomarkers.
    06/2014; DOI:10.1016/j.jchf.2014.02.005
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    ABSTRACT: AimsThe impact of refractory angina pectoris (AP) in patients with ischaemic cardiomyopathy (ICM) is unknown. We investigated the characteristics and outcomes of ICM patients with persistent AP following cardiac catheterization.Methods and resultsPatients who underwent coronary angiography at Duke from 2000 to 2009 with an EF <40% and ICM with persistent AP were compared with similar patients without persistent AP. Persistent AP was defined by patient report of ischaemic symptoms within 1 year of index catheterization. Time-to-event was examined using Kaplan–Meier or cumulative incidence and Cox proportional hazards modelling methods for death/myocardial infarction (MI)/revascularization [i.e. major adverse cardiac events (MACE)], death/MI, death, and cardiovascular death/hospitalization. Of 965 ICM patients, 298 (31%) had persistent AP. These patients were younger and had more previous revascularization than patients without persistent AP. Both groups had high use of aspirin, beta-blockers, ACE inhibitors, and statins, but modest nitrate use. Over a median follow-up of >5 years, patients with persistent AP had increased rates of MACE, and cardiovascular death/hospitalization compared with patients without persistent AP [5-year cumulative event rates of 53% vs. 46% (P = 0.013) and 73% vs. 60% (P < 0.0001), respectively], but similar rates of death (P = 0.59) and death/MI (P = 0.50). After multivariable adjustment, persistent AP remained associated with increased MACE [hazard ratio (HR) 1.30; 95% confidence interval (CI) 1.08–1.57], and cardiovascular death/hospitalization (HR 1.36; 95% CI 1.14–1.62).Conclusion Persistent AP is common despite medical therapy in patients with ICM and is independently associated with increased long-term MACE and rehospitalization. Future prospective studies of persistent AP in ICM patients are warranted.
    European Journal of Heart Failure 06/2014; 16(8). DOI:10.1002/ejhf.130 · 6.58 Impact Factor
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    ABSTRACT: -Anemia has been associated with worse outcomes in patients with chronic heart failure (HF). We aimed to characterize the clinical profile and post-discharge outcomes of hospitalized HF (HHF) patients with anemia at admission and/or discharge. -An analysis was performed on 3731/4133 (90%) of HHF patients with ejection fraction <40% enrolled in the EVEREST trial with baseline hemoglobin data, comparing the clinical characteristics and outcomes [all-cause mortality (ACM) and cardiovascular mortality (CVM) or HF hospitalization] of patients with and without anemia (hemoglobin <12g/dL for females and <13g/dL for males) on admission and/or discharge/day 7. Overall, 1277 patients (34%) were anemic at baseline, which persisted through discharge in 73% and resolved in 27%; 6% of patients without baseline anemia developed anemia by discharge/day 7. Patients with anemia were older, with lower blood pressure, and higher creatinine and natriuretic peptide levels compared to those without anemia (all P<0.05). After risk adjustment, anemia at discharge, but not admission was independently associated with increased ACM (Hazard Ratio [HR] 1.30; 95% Confidence Interval [CI], 1.05-1.60, P=0.015; and HR 0.94; 95% CI, 0.76-1.15, P=0.53, respectively) and CVM+HF hospitalization early post-discharge (≤100 days) (HR 1.73; 95% CI, 1.37-2.18, P=<0.001; and HR 0.92; 95% CI, 0.73-1.16, P=0.47, respectively). Neither baseline nor discharge anemia was associated with long-term CVM+HF hospitalization (>100 days) on adjusted analysis (both P>0.1). -Among HHF patients with reduced EF, modest anemia at discharge but not baseline was associated with increased ACM and short-term CVM+HF hospitalization. Clinical Trial Registration-URL: http://www.clinicaltrials.gov. Unique identifier: NCT00071331.
    Circulation Heart Failure 04/2014; 7(3). DOI:10.1161/CIRCHEARTFAILURE.113.000840 · 6.68 Impact Factor

Publication Stats

333 Citations
373.08 Total Impact Points

Institutions

  • 2011–2015
    • Duke University Medical Center
      • Division of Cardiology
      Durham, North Carolina, United States
    • Brigham and Women's Hospital
      • Department of Medicine
      Boston, Massachusetts, United States
  • 2012–2014
    • Duke University
      • Department of Medicine
      Durham, North Carolina, United States
    • Emory University
      • Division of Cardiology
      Atlanta, Georgia, United States
    • Northwestern University
      • Division of Cardiology (Dept. of Medicine)
      Evanston, IL, United States
  • 2013
    • Durham University
      Durham, England, United Kingdom
    • Stanford Medicine
      • Department of Medicine
      Stanford, CA, United States
  • 2012–2013
    • Harvard Medical School
      • Department of Medicine
      Boston, MA, United States