Ernst R Schwarz

Cedars-Sinai Medical Center, Los Ángeles, California, United States

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Publications (184)761.82 Total impact

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    ABSTRACT: Heart failure is a serious condition and equivalent to malignant disease in terms of symptoms burden and mortality. Presently, only a comparatively small number of heart failure patients receive specialized palliative care. A literature search was conducted with the terms, palliative care and heart failure, using the electronic databases of PubMed and MEDLINE. Nine-hundred and five articles were reviewed and of those, 78 articles discussed clinical trials in palliative care and heart failure. A complex set of management tools and strategies were used and recommended, including but not limited to lifestyle modification, exercise programs, pain and sleep disorder management, and support in end-of-life care. Limited data are available of using palliative care in heart transplant candidates prior to transplant surgery. Diminishing quality of life prevails throughout the course of chronic heart failure. Therefore, palliative care should be integrated into heart failure management. Heart transplant candidates may benefit from early palliative care involvement independent of the clinical course and outcome. Because of gaps in current scientific literature on palliative care, end-of-life care, and hospice care and the services rendered, further research is necessary to encourage healthcare professionals to introduce palliative care as an early resource in chronic disease progression.
    No preview · Article · Jan 2015 · Current Opinion in Supportive and Palliative Care
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    Dioma U Udeoji · Ernst R Schwarz
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    ABSTRACT: Coronary artery disease (CAD) and erectile dysfunction (ED) frequently coexist. The introduction of phosphodiesterase type-5 (PDE-5) inhibitors has revolutionized medical management of organic ED; however, in patients with angina pectoris, a common symptom of CAD, coadministration of PDE-5 inhibitors and nitrates has been implicated in CAD-related deaths following sexual activity. The mechanism of action of PDE-5 inhibitors results in a potential cumulative drop in blood pressure (BP); thus, these agents are contraindicated in patients receiving nitrates. Beta-blockers and calcium channel antagonists are considered the mainstays of antianginal therapy, but may not be tolerated by all patients. Ranolazine is an antianginal agent that produces minimal reductions in heart rate and BP. Here we report three cases of men with CAD, chronic angina, and concomitant ED. We describe our treatment approach in these patients, using ranolazine as a potential substitute to nitrate therapy.
    Full-text · Article · Nov 2014 · Clinical Medicine Insights: Case Reports
  • Olivia S Biswas · Viviana R Gonzalez · Ernst R Schwarz
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    ABSTRACT: Nitric oxide (NO) is an integral molecule especially important in the regulation of the cardiovascular system. Literature indicates that the number of studies continues to grow with regard to the effects of NO on cardiovascular disease and hypertension. "Prehypertension" is the clinical stage leading to hypertension. Diet and lifestyle modifications are the only treatment options for prehypertension. The objective of this study was to determine the effects of oral NO supplementation on blood pressure in patients with clinical prehypertension. This pilot phase study evaluated the effect of an orally disintegrating lozenge that generates NO in the oral cavity on blood pressure, functional capacity, and quality of life. Thirty patients with clinical prehypertension were recruited and enrolled in either the NO treatment or the placebo group over a 30-day period in an outpatient setting. Nitric oxide supplementation resulted in a significant decrease in resting blood pressure (138 ± 12 mm Hg in systole and 84 ± 5 mm Hg in diastole at baseline vs 126 ± 12 mm Hg in systole and 78 ± 4 mm Hg in diastole at follow-up, P < .001, vs baseline) and a significant increase in the achieved walking distance in the standard 6-minute walk test (596 ± 214 meters at baseline vs 650 ± 197 meters at follow-up, P < .005 vs baseline). Using a standardized questionnaire to assess quality of life, patients receiving NO supplementation showed improvement in the Physical Component Summary Score (PCS) and Mental Component Summary Score (MCS). Nitric oxide supplementation appears to lower blood pressure in patients with prehypertension and might be beneficial as a routine supplementation for cardiovascular protection.
    No preview · Article · Jun 2014 · Journal of Cardiovascular Pharmacology and Therapeutics
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    ABSTRACT: To ascertain the beneficial role of spiritual counseling in patients with chronic heart failure. This is a pilot study evaluating the effects of adjunct spiritual counseling on quality of life (QoL) outcomes in patients with heart failure. Patients were assigned to "religious" or "non-religious" counseling services based strictly on their personal preferences and subsequently administered standardized QoL questionnaires. A member of the chaplaincy or in-house volunteer organization visited the patient either daily or once every 2 days throughout the duration of their hospitalization. All patients completed questionnaires at baseline, at 2 weeks, and at 3 months. Each of the questionnaires was totaled, with higher scores representing positive response, except for one survey measure where lower scores represent improvement (QIDS-SR16). Twenty-three patients (n = 23, age 57 ± 11, 11 (48 %) male, 12 (52 %) female, mean duration of hospital stay 20 ± 15 days) completed the study. Total mean scores were assessed on admission, at 2 weeks and at 3 months. For all patients in the study, the mean QIDS-SR16 scores were 8.5 (n = 23, SD = 3.3) versus 6.3 (n = 18, SD = 3.5) versus 7.3 (n = 7, SD = 2.6). Mean FACIT-Sp-Ex (version 4) scores were 71.1 (n = 23, SD = 15.1) versus 74.7 (n = 18, SD = 20.9) versus 81.4 (n = 7, SD = 8.8). The mean MSAS scores were 2.0 (n = 21, SD = 0.6) versus 1.8 (n = 15, SD = 0.7) versus 2.5 (n = 4, SD = 0.7). Mean QoL Enjoyment and Satisfaction scores were 47.2 % (n = 23, SD = 15.0 %) versus 53.6 % (n = 18, SD = 16.4 %) versus 72.42 % (n = 7, SD = 22 %). The addition of spiritual counseling to standard medical management for patients with chronic heart failure patients appears to have a positive impact on QoL.
    No preview · Article · Apr 2014 · Journal of Religion and Health
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    ABSTRACT: Cardiovascular Case Report Posters ISESSION TYPE: Affiliate Case Report PosterPRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PMINTRODUCTION: Left ventricular assist device (LVAD) therapy as a bridge to transplantation or destination therapy has improved survival and quality of life in end-stage heart failure. Despite these benefits, it has many complications. We describe a patient with extensive pulmonary thromboembolic disease as a complication of VAD therapy.CASE PRESENTATION: A 47-year-old male with idiopathic dilated cardiomyopathy had a HeartMate II LVAD inserted as bridge to transplantation. He resumed work and exercise. Months later his dyspnea progressed. Chest computed tomography (CT) scan showed multiple pulmonary nodules, diagnosed as atypical pneumonia and treated with moxifloxacin. Transesophageal echocardiogram showed no vegetations. Microbiology was negative. More significantly, he developed right ventricular dysfunction. A TandemHeart RVAD was urgently placed. He improved and was transferred to our institution for a total artificial heart (TAH). On arrival, he was asymptomatic and stable, though bed bound and on full anticoagulation due to the bi-VAD. Repeat chest CT showed progression of numerous irregular pulmonary nodules (Fig 1). Infectious and autoimmune work up was negative. Bronchoscopy with lavage showed diffuse alveolar hemorrhage but negative microbiology and cytology. With still no definitive etiology, anticoagulation was held and video-assisted thoracoscopic biopsy performed. It showed focal organizing thromboembolism in a pulmonary arteriole, consistent with bland emboli from the devices. TAH placement was pursued but was complicated by massive pulmonary hemorrhage likely due to these infarcts. The family withdrew care and the patient expired.DISCUSSION: Over 6,885 patients have received an FDA-approved durable mechanical circulatory support device. While often used as bridge to transplant, in 2012 more than 40% were destination therapy. Despite significant therapeutic advantages, VAD support has many complications, including bleeding, infection, arrhythmia, respiratory failure, right heart failure, thromboembolism, stroke, and hemolysis. As these devices become more common, the chest physician must become familiar with their mechanism and complications. Our patient had extensive pulmonary thromboembolic disease due to the VAD. Particularly interesting is that the onset occurred when the patient had an LVAD only, though it did progress after RVAD insertion. Thromboembolic complications of LVADs are common, but usually present as stroke or device thrombosis. Pulmonary thromboembolic disease is not commonly reported.CONCLUSIONS: VAD therapy is widely used to treat advanced heart failure. It is important for the chest physician to be familiar with its complications, particularly potential pulmonary complications of infection, bleeding, and thromboembolic disease.Reference #1: JK Kirklin, et al. Fifth INTERMACS annual report: Risk factor analysis from more than 6,000 mechanical circulatory support patients. J Heart Lung Transplant. Vol 32, Iss 2, Feb 2013, 141-156DISCLOSURE: The following authors have nothing to disclose: Corinne Sheth, Heather Merry, Lawrence Czer, Ernst Schwarz, Danny Ramzy, Fardad Esmailian, George ChauxNo Product/Research Disclosure Information.
    Full-text · Article · Oct 2013 · Chest
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    ABSTRACT: The first case of noncompaction was described in 1932 after an autopsy performed on a newborn infant with aortic atresia/coronary-ventricular fistula. Isolated noncompaction cardiomyopathy was first described in 1984. A review on selected/relevant medical literature was conducted using Pubmed from 1984 to 2013 and the pathogenesis, clinical features, and management are discussed. Left ventricular noncompaction (LVNC) is a relatively rare congenital condition that results from arrest of the normal compaction process of the myocardium during fetal development. LVNC shows variability in its genetic pattern, pathophysiologic findings, and clinical presentations. The genetic heterogeneity, phenotypical overlap, and variety in clinical presentation raised the suspicion that LVNC might just be a morphological variant of other cardiomyopathies, but the American Heart Association classifies LVNC as a primary genetic cardiomyopathy. The familiar type is common and follows a X-linked, autosomal-dominant, or mitochondrial-inheritance pattern (in children). LVNC can occur in isolation or coexist with other cardiac and/or systemic anomalies. The clinical presentations are variable ranging from asymptomatic patients to patients who develop ventricular arrhythmias, thromboembolism, heart failure, and sudden cardiac death. Increased awareness over the last 25 years and improvements in technology have increased the identification of this illness and improved the clinical outcome and prognosis. LVNC is commonly diagnosed by echocardiography. Other useful diagnostic techniques for LVNC include cardiac magnetic resonance imaging, computerized tomography, and left ventriculography. Management is symptom based and patients with symptoms have a poorer prognosis. LVNC is a genetically heterogeneous disorder which can be associated with other anomalies. Making the correct diagnosis is important because of the possible associations and the need for long-term management and screening of living relatives.
    No preview · Article · Oct 2013 · Therapeutic Advances in Cardiovascular Disease

  • No preview · Article · Aug 2013 · Journal of Cardiac Failure
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    ABSTRACT: Ventricular assist device (VAD) implantation as a bridge to cardiac transplantation is an effective treatment option for end-stage heart failure. Renal dysfunction is not uncommon but is considered to be a poor prognostic factor. We present our experience with 6 patients who had combined heart and kidney transplantation (HKT) after VAD implantation for advanced cardiac and renal failure. Of 74 patients who underwent VAD implantation as a bridge to transplant from May 2001 to September 2009, 28 patients developed renal failure, and of these, 6 (5 male, 1 female, ages 40-64 years) had HKT. All required hemodialysis because of renal failure before HKT. Immunosuppression consisted of anti-thymocyte globulin followed by triple drug therapy consisting of calcineurin inhibitors, mycophenolate, and corticosteroids. Of the 6 HKT patients, 5 (83%) were alive without hemodialysis at 1 and 2 years; of the 22 patients with renal failure after VAD implantation without subsequent transplant, 1- and 2-year survivals were zero. Interval from VAD implantation to HKT ranged from 36 to 366 days (133 ± 127 days). At 6 months after HKT (100% alive), left ventricular ejection fraction was 60.2 ± 5.8% and serum creatinine 1.1 ± 0.2 mg/dL. Three HKT patients required temporary hemodialysis after surgery. Endomyocardial biopsy showed absence of ISHLT grade 2R-3A or greater cellular rejection, and none showed evidence of definite antibody-mediated rejection. Based on our initial experience, simultaneous HKT is a safe treatment option with excellent outcomes for patients with advanced heart failure and persistent renal dysfunction after VAD implantation.
    Full-text · Article · Jul 2013 · Transplantation Proceedings
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    ABSTRACT: Heart failure (HF) is the most common reason for hospital admission for patients older than 65 years. With an aging population and improving survival in heart failure patients, the number of people living with HF continues to grow. As this population increases, the importance of treating symptoms of fatigue, dyspnea, pain, and depression that diminish the quality of life in HF patients becomes increasingly important. Palliative care has been shown to help alleviate these symptoms and improve patients' satisfaction with the care they receive. Despite this growing body of evidence, palliative care consultation remains underutilized and is not standard practice in the management of HF. With an emphasis on communication, symptom management, and coordinated care, palliative care provides an integrated approach to support patients and families with chronic illnesses. Early communication with patients and families regarding the unpredictable nature of HF and the increased risk of sudden cardiac death enables discussions around advanced care directives, health care proxies, and deactivation of permanent pacemakers or implantable cardioverter defibrillators. Cardiologists and primary care physicians who are comfortable initiating these discussions are encouraged to do so; however, many fear destroying hope and are uncertain how to discuss end-of-life issues. Thus, in order to facilitate these discussions and establish an appropriate relationship, we recommend that patients and families be introduced to a palliative care team at the earliest appropriate time after diagnosis.
    No preview · Article · May 2013 · Reviews in cardiovascular medicine
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    Full-text · Dataset · May 2013
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    Full-text · Dataset · May 2013
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    Full-text · Dataset · May 2013
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    ABSTRACT: Background: Heart failure is characterized by recurrent decompensations and persistent symptoms that decrease quality of life. Shortness of breath and fatigue are commonly identified symptoms but there is limited data on pain in heart failure patients. The Edmonton Symptom Assessment System (ESAS) was used to identify the prevalence and severity of pain and other symptoms experienced by patients with acute decompensated heart failure. Methods: This is a cross-sectional study that evaluated patients with a history of chronic heart failure admitted to the hospital with acute decompensated heart failure. A standardized questionnaire (ESAS) was administered to patients within 24 hours of hospital admission. Exclusion criteria included patients <18 years of age, admission for a noncardiac reason, active malignancy, history of chronic pain, outpatient chronic pain medication use, and those actively followed by the palliative care service. Results: One hundred patients, 67 males, with a mean age of 58 ± 17 years were recruited. The mean ejection fraction (EF) was 37%± 18%. Sixty patients (60%) reported pain of any degree. Patients with lower EF (≤ 40%, n=61) reported significantly higher pain scores (4.1 ± 3.6) compared to patients with higher EF (>40%, n=36, 2.7 ± 3.4, p<0.05). Tiredness, shortness of breath, and decreased well-being were the most severe symptoms with mean scores of 6.3 ± 2.8, 6.1 ± 3.1, and 5.7 ± 2.6, respectively. Conclusion: Pain is a common, underrecognized symptom in patients with chronic but acute decompensated heart failure. Decreased well-being, shortness of breath, and tiredness are the most common and severe symptoms in patients with chronic heart failure, regardless of ejection fraction.
    No preview · Article · Dec 2012 · Journal of palliative medicine
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    ABSTRACT: Heart failure (HF) is a chronic progressive disease with marked morbidity and mortality. Patients enduring this condition suffer from fluctuations in symptom burden such as fatigue, shortness of breath, chest pain, sexual dysfunction, dramatic changes in body image and depression. As physicians, we often ask patients to trust in our ability to ameliorate their symptoms, but oftentimes we do not hold all of the answers, and our best efforts are only modestly effective. The suffering endured by these individuals and their families may even call into question one's faith in a higher power and portends to significant spiritual struggle. In the face of incurable and chronic physical conditions, it seems logical that patients would seek alternative or ancillary methods, notably spiritual ones, to improve their ability to deal with their condition. Although difficult to study, spirituality has been evaluated and deemed to have a beneficial effect on multiple measures including global quality of life, depression and medical compliance in the treatment of patients with HF. The model of HF treatment incorporates a multidisciplinary approach. This should involve coordination between primary care, cardiology, palliative care, nursing, patients and, importantly, individuals providing psychosocial as well as spiritual support. This review intends to outline the current understanding and necessity of spirituality's influence on those suffering from HF.
    No preview · Article · Dec 2012 · Journal of Religion and Health
  • Dioma U Udeoji · Ernst R Schwarz
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    ABSTRACT: The purpose of this review is to evaluate the use of tadalafil as monotherapy and in combination regimens for the treatment of pulmonary arterial hypertension (PAH). A systematic English language search of the medical literature using PubMed was conducted between January 1960 and May 2012 using the search terms 'tadalafil', 'therapy', 'pulmonary (arterial) hypertension' and 'combination therapy'. Special emphasis was given to controlled clinical trials and case studies relevant for the use of tadalafil in PAH. The search revealed 113 relevant publications, 31 of which were clinical trials, 52 were reviews and 12 were case reports. Of these, 12 were clinical studies in human patients with PAH who were treated with tadalafil alone, and seven were clinical studies in human patients with PAH who were treated with tadalafil in combination with other agents. Only clinical studies in human patients were included. Exclusion criteria were monotherapy other than using tadalafil and any combination therapy that excluded tadalafil as part of the treatment regimen. Overall, 1353 human subjects were studied; 896 were treated with tadalafil alone while 457 subjects were treated with tadalafil in coadministration. Tadalafil appears to be an effective and a safe treatment option for patients with PAH. It improves clinical status, exercise capacity, hemodynamic parameters, compliance issues and quality of life and reduces the occurrence of clinical worsening. Tadalafil in combination therapy seems to be additive and synergistic in relaxing pulmonary vascular muscle cells but more clinical trials on human subjects are warranted.
    No preview · Article · Nov 2012 · Therapeutic Advances in Respiratory Disease
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    ABSTRACT: Background Cell therapy (CTh) is a promising novel therapy for myocardial infarction (MI) and ischemic cardiomyopathy (iCMP). Recognizing adverse events (AE) is important for safety evaluation, harm prevention and may aid in the design of future trials. Objective To define the prevalence of periprocedural AE in CTh trials in MI and iCMP. Methods A literature search was conducted using the MEDLINE database from January 1990 to October 2010. Controlled clinical trials that compared CTh with standard treatment in the setting of MI and/or iCMP were selected. AE related to CTh were analyzed. Results A total of 2,472 patients from 35 trials were included. There were 26 trials including 1,796 patients that used CTh in MI and 9 trials including 676 patients that used CTh in iCMP. Periprocedural arrhythmia monitoring protocols were heterogeneous and follow-up was short in most of the trials. In MI trials, the incidence of periprocedural adverse events (AE) related to intracoronary cell transplantation was 7.5 % (95 % CI 6.04–8.96 %). AE related to granulocyte colony-stimulating factor (GCS-F) used for cell mobilization for peripheral apheresis was 16 % (95 % CI 9.44–22.56 %). During intracoronary transplantation in iCMP, the incidence of periprocedural AE incidence was 2.6 % (95 % CI 0.53–4.67 %). There were no AE reported during transepicardial transplantation and AE were rare during transendocardial transplantation. Conclusions The majority of periprocedural AE in CTh trials in MI occurred during intracoronary transplantation and GCS-F administration. In iCMP, periprocedural AE were uncommon. Avoiding intracoronary route for CTh implantation may decrease the burden of periprocedural AE. Standardization of AE definition in CTh trials is needed.
    No preview · Article · Sep 2012 · Clinical Research in Cardiology
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    ABSTRACT: To evaluate the prevalence and severity of pain in patients with chronic stable heart failure (HF) in an outpatient clinic setting. This is a cross-sectional study evaluating symptoms of generalized or specific pain in patients with chronic stable heart failure. A standardized questionnaire (Edmonton Symptom Assessment System) was administered during a routine outpatient clinic visit. The severity of pain and other symptoms were assessed on a 10 point scale with 10 being the worst and 0 representing no symptoms. Sixty-two patients [age 56 ± 13 years, 51 males, 11 females, mean ejection fraction (EF) 33% ± 17%] completed the assessment. Thirty-two patients (52%) reported any pain of various character and location such as chest, back, abdomen or the extremities, with a mean pain score of 2.5 ± 3.1. Patients with an EF less than 40% (n = 45, 73%) reported higher pain scores than patients with an EF greater than 40% (n = 17, 27%), scores were 3.1 ± 3.3 vs 1.2 ± 1.9, P < 0.001. Most frequent symptoms were tiredness (in 75% of patients), decreased wellbeing (84%), shortness of breath (SOB, 76%), and drowsiness (70%). The most severe symptom was tiredness with a score of 4.0 ± 2.8, followed by decreased wellbeing (3.7 ± 2.7), SOB (3.6 ± 2.8), and drowsiness (2.8 ± 2.8). Pain appears to be prevalent and significantly affects quality of life in HF patients. Adequate pain assessment and management should be an integral part of chronic heart failure management.
    Full-text · Article · Aug 2012 · World Journal of Cardiology (WJC)
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    Keith A Thompson · Ryan P Morrissey · Anita Phan · Ernst R Schwarz
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    ABSTRACT: To determine the effects of the US economy on heart failure hospitalization rates. The recession was associated with worsening unemployment, loss of private insurance and prescription medication benefits, medication nonadherence, and ultimately increased rates of hospitalization for heart failure. We compared hospitalization rates at a large, single, academic medical center from July 1, 2006 to February 28, 2007, a time of economic stability, and July 1, 2008 to February 28, 2009, a time of economic recession in the United States. Significantly fewer patients had private medical insurance during the economic recession than during the control period (36.5% vs 46%; P = 0.04). Despite this, there were no differences in the heart failure hospitalization or readmission rates, length of hospitalization, need for admission to an intensive care unit, in-hospital mortality, or use of guideline-recommended heart failure medications between the 2 study periods. We conclude that despite significant effects on medical insurance coverage, rates of heart failure hospitalization at our institution were not significantly affected by the recession. Additional large-scale population-based research is needed to better understand the effects of fluctuations in the US economy on heart failure hospitalization rates.
    Preview · Article · Aug 2012 · Clinical Cardiology
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    Melody Zaya · Anita Phan · Ernst R Schwarz
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    ABSTRACT: Heart failure (HF) is a chronic, progressive illness that is highly prevalent in the United States and worldwide. This morbid illness carries a very poor prognosis, and leads to frequent hospitalizations. Repeat hospitalization in HF is both largely burdensome to the patient and the healthcare system, as it is one of the most costly medical diagnoses among Medicare recipients. For years, investigators have strived to determine methods to reduce hospitalization rates of HF patients. Despite such efforts, recent reports indicate that re-hospitalization rates remain persistently high, without any improvement over the past several years and thus, this topic clearly needs aggressive attention. We performed a key-word search of the literature for relevant citations. Published articles, limited to English abstracts indexed primarily in the PubMed database through the year 2011, were reviewed. This article discusses various clinical parameters, serum biomarkers, hemodynamic parameters, and psychosocial factors that have been reviewed in the literature as predictors of re-hospitalization of HF patients. With this information, our hope is that the future holds better risk-stratification models that will allow providers to identify high-risk patients, and better customize effective interventions according to the needs of each individual HF patient.
    Full-text · Article · Feb 2012 · World Journal of Cardiology (WJC)
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    ABSTRACT: Heart failure (HF) in its chronic form is an irreversible and progressive disease. Palliative care (PC) interventions have traditionally been focused on patients with advanced cancer. We performed a pilot study to assess the feasibility of implementing the American College of Cardiology/American Heart Association (ACC/AHA) guidelines for early PC intervention in patients with advanced HF who were seeking or received potentially curative therapies. Twenty consecutive patients with advanced HF referred to PC from the heart transplant service with stage D, New York Heart Association (NYHA) class III-IV symptoms were analyzed retrospectively in a tertiary care setting. Data were reviewed to assess the clinical impact of PC intervention. Feedback was obtained to assess satisfaction of the patients, their families, and the health care professionals. An independent assessment of the impact of the PC service in the care of each patient was performed by a cardiologist and PC physician by use of a scoring system. Twenty consecutive patients with HF were analyzed. PC consult was obtained for a variety of reasons. All patients complained of a high symptom burden. PC consultation resulted in a decrease in the use of opioids and increased patient satisfaction. Patients and their family members generally reported improved holistic care, continuity of care, more focused goals of care, and improved planning of treatment courses. The nonstandardized scoring system used to determine the impact of the PC service showed an average of moderate to significant impact when assessed by both a cardiologist and a PC physician. PC consultation appears to be beneficial in the treatment and quality of life of advanced HF patients, independent of their prognosis. This pilot study demonstrated feasibility and sufficient evidence of clinical benefit to warrant a larger randomized clinical trial assessing the benefit of standard involvement by PC in patients with advanced HF, independent of the patient's prognosis or treatment goals.
    No preview · Article · Jan 2012 · Journal of palliative medicine

Publication Stats

3k Citations
761.82 Total Impact Points


  • 2007-2015
    • Cedars-Sinai Medical Center
      • • Cedars Sinai Medical Center
      • • Department of Medicine
      Los Ángeles, California, United States
  • 2011
    • Penn State Hershey Medical Center and Penn State College of Medicine
      • Heart and Vascular Institute
      Hershey, Pennsylvania, United States
  • 1997-2009
    • University Hospital RWTH Aachen
      • Department of Neurology
      Aachen, North Rhine-Westphalia, Germany
  • 2008
    • CSU Mentor
      Long Beach, California, United States
  • 2006-2008
    • University of California, Los Angeles
      • Division of Cardiology
      Los Angeles, California, United States
  • 2005-2008
    • University of Texas Medical Branch at Galveston
      • • Department of Internal Medicine
      • • Division of Cardiology
      Galveston, Texas, United States
  • 2004-2008
    • Texas A&M University - Galveston
      Galveston, Texas, United States
    • Royal Brompton and Harefield NHS Foundation Trust
      Harefield, England, United Kingdom
    • Imperial College London
      Londinium, England, United Kingdom
  • 1995-2004
    • RWTH Aachen University
      • Institute of Medical Statistics
      Aachen, North Rhine-Westphalia, Germany
  • 1998-2000
    • University of Southern California
      • Department of Medicine
      Los Angeles, California, United States
    • Max Planck Institute for Informatics
      Saarbrücken, Saarland, Germany
    • Good Samaritan Hospital
      Cincinnati, Ohio, United States
  • 1997-2000
    • Good Samaritan Hospital Los Angeles
      Los Angeles, California, United States