Lynne Warner Stevenson

Harvard University, Cambridge, Massachusetts, United States

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Publications (467)4694.98 Total impact

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    ABSTRACT: Background: -Patients with advanced heart failure may persist for prolonged times with persistent hemodynamic abnormalities; intermediate and long-term outcomes of these patients are unknown. Methods and results: -We used ESCAPE trial data to examine characteristics and outcomes of patients with invasive hemodynamic monitoring during an acute heart failure hospitalization. Patients were stratified by final measurement of cardiac index (CI; L/min/m2) and pulmonary capillary wedge pressure (PCWP; mmHg) before catheter removal. The study groups were CI ≥ 2/PCWP <20 (n = 74), CI ≥ 2/PCWP ≥ 20 (n = 37), CI < 2/PCWP < 20 (n = 23), and CI < 2/PCWP ≥ 20 (n = 17). Final CI was not associated with the combined risk of death, cardiovascular hospitalization, and transplantation (HR:1.03, 95% CI:0.96-1.11 per 0.2 L/min/m(2) decrease, p=0.39), but final PCWP ≥ 20mmHg was associated with increased risk of these events (HR:2.03, 95% CI:1.31-3.15, p<0.01), as was higher final right atrial pressure (RAP; HR:1.09, 95% CI:1.06-1.12 per mmHg increase, p<0.01). Conclusion: -Final PCWP and final RAP were stronger predictors of post-discharge outcomes than CI in patients with advanced heart failure. The ability to lower filling pressures appears to be more prognostically important than improving CI in the management of patients with advanced heart failure.
    No preview · Article · Dec 2015 · Journal of cardiac failure
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    ABSTRACT: Objectives: This study sought to evaluate the effectiveness of intravenous (IV) diuretic treatment for volume management in heart failure (HF). Background: Limited data exist regarding IV diuretics for the outpatient treatment of volume overload in HF patients. Methods: We analyzed 60 consecutive patients with chronic HF and clinical evidence of worsening congestion who received a bolus and 3-h IV infusion of furosemide at an outpatient HF clinic. Diuretic dosing was derived from the maintenance oral loop diuretic dose with a standardized conversion algorithm. Outcomes included urine output during the visit, weight loss at 24 h, and hospitalization and mortality at 30 days. Safety outcomes included hypokalemia and worsening of renal function. Outcomes were analyzed across subgroups defined by maintenance diuretic dose and ejection fraction (EF). Results: The median age of the cohort was 70 years (interquartile range [IQR], 58 to 80 years), and the median daily loop diuretic dose was 240 mg (IQR, 80 to 800 mg) oral furosemide or equivalent. Twenty-six patients (43.3%) were women, and 36 (60%) had an EF ≤45%. For the entire cohort, the median urine output and 24-h weight loss were 1.1 l (IQR, 0.6 to 1.4 l) and 1.1 kg (IQR, 0.2 to 1.9 kg), respectively. Outcomes were similar across patients with varying maintenance diuretic doses (<40 mg, 40 to 160 mg, 160 to 300 mg, or >300 mg of furosemide or equivalent) and in patients with reduced or preserved EF. Transient worsening of renal function and hypokalemia occurred in 10 patients (8.9%) and 4 patients (3.5%). Although hospitalization was reported as imminent for 28 patients (52.8%), the observed rate of all-cause hospitalization was 31.7% at 30-days with no deaths. Conclusions: Short courses of IV diuretics for volume management in patients with HF were safe and associated with significant urine output and weight loss across a wide range of maintenance diuretic doses and EF. This strategy may provide an alternative to hospitalization for the management of selected HF patients.
    No preview · Article · Dec 2015 · JACC: Heart Failure
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    ABSTRACT: Background Pump thrombosis in durable continuous-flow pumps is a barrier to long-term mechanical circulatory support. Earlier Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) data identified an increasing risk of pump thrombosis in recent years with the HeartMate II (HMII) left ventricular assist device. The current analysis examines pump thrombosis in the patient cohort extended through June 2014. Methods The INTERMACS identified 9,808 adult patients from 144 institutions receiving a primary HMII implant between April 2008 and June 30, 2014. Pump thrombosis was identified at time of explant, transplant or death. Risk factors for pump thrombosis were examined by multivariable analysis in the hazard function domain. The association between pump thrombosis and implant year was modeled in the hazard domain. Results Parametric hazard modeling of thrombosis by year of implant identified an increasing risk of pump thrombosis from 2009 through 2013, followed by a decrease in the risk during the first half of 2014, which was most apparent during the first 3 months post-implant. Risk factors for pump thrombosis included younger age (p < 0.001), higher body mass index (p = 0.02), history of non-compliance (p = 0.004), severe right heart failure (p = 0.02), later date of implant (p < 0.0001), and elevated lactate dehydrogenase during the first month post-implant (p < 0.0001). Subsequent pump thrombosis was more likely if the initial pump exchange indication was pump thrombosis (p < 0.0001). Conclusions The small, but progressive increase in the incidence of pump thrombosis observed between 2010 and 2013 with the HMII pump had reversed somewhat in the first half of 2014. Identification of marked elevation of lactate dehydrogenase during the first month offers an opportunity for early intervention strategies. © 2015 International Society for Heart and Lung Transplantation.
    No preview · Article · Dec 2015 · The Journal of Heart and Lung Transplantation
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    ABSTRACT: Background: In the CHAMPION trial, significant reductions in admissions to hospital for heart failure were seen after 6 months of pulmonary artery pressure guided management compared with usual care. We examine the extended efficacy of this strategy over 18 months of randomised follow-up and the clinical effect of open access to pressure information for an additional 13 months in patients formerly in the control group. Methods: The CHAMPION trial was a prospective, parallel, single-blinded, multicentre study that enrolled participants with New York Heart Association (NYHA) Class III heart failure symptoms and a previous admission to hospital. Patients were randomly assigned (1:1) by centre in block sizes of four by a secure validated computerised randomisation system to either the treatment group, in which daily uploaded pulmonary artery pressures were used to guide medical therapy, or to the control group, in which daily uploaded pressures were not made available to investigators. Patients in the control group received all standard medical, device, and disease management strategies available. Patients then remained masked in their randomised study group until the last patient enrolled completed at least 6 months of study follow-up (randomised access period) for an average of 18 months. During the randomised access period, patients in the treatment group were managed with pulmonary artery pressure and patients in the control group had usual care only. At the conclusion of randomised access, investigators had access to pulmonary artery pressure for all patients (open access period) averaging 13 months of follow-up. The primary outcome was the rate of hospital admissions between the treatment group and control group in both the randomised access and open access periods. Analyses were by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT00531661. Findings: Between Sept 6, 2007, and Oct 7, 2009, 550 patients were randomly assigned to either the treatment group (n=270) or to the control group (n=280). 347 patients (177 in the former treatment group and 170 in the former control group) completed the randomised access period in August, 2010, and transitioned to the open access period which ended April 30, 2012. Over the randomised access period, rates of admissions to hospital for heart failure were reduced in the treatment group by 33% (hazard ratio [HR] 0·67 [95% CI 0·55-0·80]; p<0·0001) compared with the control group. After pulmonary artery pressure information became available to guide therapy during open access (mean 13 months), rates of admissions to hospital for heart failure in the former control group were reduced by 48% (HR 0·52 [95% CI 0·40-0·69]; p<0·0001) compared with rates of admissions in the control group during randomised access. Eight (1%) device-related or system related complications and seven (1%) procedure-related adverse events were reported. Interpretation: Management of NYHA Class III heart failure based on home transmission of pulmonary artery pressure with an implanted pressure sensor has significant long-term benefit in lowering hospital admission rates for heart failure. Funding: St Jude Medical Inc.
    No preview · Article · Nov 2015 · The Lancet

  • No preview · Article · Oct 2015 · The Journal of Heart and Lung Transplantation
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    ABSTRACT: The seventh annual report of the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) summarizes the first 9 years of patient enrollment. The Registry includes >15,000 patients from 158 participating hospitals. Trends in device strategy, patient profile at implant and survival are presented. Risk factors for mortality with continuous-flow pumps are updated, and the major causes/modes of death are presented. The adverse event burden is compared between eras, and health-related quality of life is reviewed. A detailed analysis of outcomes after mechanical circulatory support for ambulatory heart failure is presented. Recent summary data from PediMACS and MedaMACS is included. With the current continuous-flow devices, survival at 1 and 2 years is 80% and 70%, respectively. © 2015 International Society for Heart and Lung Transplantation.
    No preview · Article · Oct 2015 · The Journal of Heart and Lung Transplantation
  • Sean P Pinney · Lynne Warner Stevenson

    No preview · Article · Sep 2015 · Circulation Heart Failure
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    ABSTRACT: Rate and rhythm control strategies for atrial fibrillation (AF) are not always effective or well tolerated in patients with congestive heart failure (CHF). We assessed reasons for treatment failure, associated characteristics, and effects on survival. 1,376 patients enrolled in the AF-CHF trial were followed for 37±19 months, 206 (15.0%) of whom failed initial therapy leading to crossover. Rhythm control was abandoned more frequently than rate control (21.0% versus 9.1%, P<0.0001). Crossovers from rhythm to rate control were driven by inefficacy, whereas worsening heart failure was the most common reason to crossover from rate to rhythm control. In multivariate analyses, failure of rhythm control was associated with female sex, higher serum creatinine, functional class III or IV symptoms, lack of digoxin, and oral anticoagulation. Factors independently associated with failure of rate control were paroxysmal (versus persistent) AF, statin therapy, and presence of an implantable cardioverter-defibrillator. Crossovers were not associated with cardiovascular mortality [hazard ratio (HR) 1.11 from rhythm to rate control, 95% confidence interval (CI; 0.73, 1.73), P = 0.6069; HR 1.29 from rate to rhythm control, 95% CI (0.73, 2.25), P = 0.3793] or all-cause mortality [HR 1.16 from rhythm to rate control, 95% CI (0.79, 1.72), P = 0.4444; HR 1.15 from rate to rhythm control, 95% (0.69, 1.91), P = 0.5873]. Rhythm control is abandoned more frequently than rate control in patients with AF and CHF. The most common reasons for treatment failure are inefficacy for rhythm control and worsening heart failure for rate control. Changing strategies does not impact survival. This article is protected by copyright. All rights reserved. This article is protected by copyright. All rights reserved.
    No preview · Article · Sep 2015 · Journal of Cardiovascular Electrophysiology

  • No preview · Article · Aug 2015 · The Journal of heart and lung transplantation: the official publication of the International Society for Heart Transplantation

  • No preview · Article · Aug 2015 · Journal of Cardiac Failure
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    ABSTRACT: To examine the effectiveness of primary implantable cardioverter defibrillators (ICDs) in elderly patients receiving the device during a hospital admission for exacerbation of heart failure or other acute co-morbidities, with an emphasis on adjustment for early mortality and other factors reflecting healthy candidate bias rather than the effect of the ICD. Retrospective cohort study. Linked data from the Centers for Medicare and Medicaid Services and American College of Cardiology-National Cardiovascular Data Registry ICD registry, nationwide heart failure registry, and Medicare claims data 2004-09. 23 111 patients aged ≥66 who were admitted to hospital for exacerbation of heart failure or other acute co-morbidities and eligible for primary ICDs. All cause mortality and sudden cardiac death. Latency analyses with Cox regression were used to derive crude hazard ratios and hazard ratios adjusted for high dimension propensity score for outcomes after 180 days from index implantation or discharge. Patients who received an ICD during a hospital admission had lower crude mortality risk than patients who did not receive an ICD (40% v 60% at three years); however, with conditioning on 180 day survival and with adjustment for high dimension propensity score, the apparent benefit with ICD was no longer evident for sudden cardiac death (adjusted hazard ratio 0.95, 95% confidence interval 0.78 to 1.17) and had a diminished impact on total mortality (0.91, 0.82 to 1.00). There were trends towards a benefit with ICD in reducing mortality or sudden cardiac death in patients who had had a myocardial infarction more than 40 days previously, left bundle branch block, or low serum B type natriuretic peptide; however, these trends did not reach significance. After adjustment for healthy candidate bias and confounding, the benefits of primary ICD therapy seen in pivotal trials were not apparent in patients aged 66 or over who received ICDs during a hospital admission for exacerbation of heart failure or other acute co-morbidities. Future research is warranted to further identify subgroups of elderly patients who are more likely to benefit from ICDs. Recognition of those patients whose dominant risk factors are from decompensated heart failure and non-cardiac co-morbidities will allow better focus on ICDs in those patients for whom the device offers the most benefit and provides meaningful prolonging of life. © Chen et al 2015.
    Full-text · Article · Jul 2015 · BMJ (online)
  • Lynne Warner Stevenson · James E Udelson

    No preview · Article · Jul 2015 · Circulation Heart Failure
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    ABSTRACT: -Congestion is the most frequent cause for hospitalization in acute decompensated heart failure (ADHF). Although decongestion is a major goal of acute therapy, it is unclear how the clinical components of congestion (e.g., peripheral edema, orthopnea) contribute to outcomes after discharge or how well decongestion is maintained. -A post-hoc analysis was performed of 496 patients enrolled in the DOSE-AHF and CARRESS-HF trials during hospitalization with ADHF and clinical congestion. A simple "orthodema" congestion score was generated based on symptoms of orthopnea (≥2 pillows=2 points, <2 pillows=0 points) and peripheral edema (trace=0 points, moderate=1 point, severe=2 points) at baseline, discharge, and 60-day follow-up. Orthodema scores were classified as absent (score of 0), low-grade (score of 1-2), and high-grade (score of 3-4), and the association with death, rehospitalization or unscheduled medical visits through 60 days was assessed. At baseline, 65% of patients had high-grade orthodema and 35% had low-grade orthodema. At discharge, 52% patients were free from orthodema at discharge (score = 0) and these patients had lower 60-day rates of death, rehospitalization, or unscheduled visits (50%) compared to those with low-grade or high-grade orthodema (52% and 68%, respectively, p=0.038). Of the patients without orthodema at discharge, 27% relapsed to low-grade orthodema and 38% to high-grade orthodema at 60-day follow-up. -Increased severity of congestion by a simple orthodema assessment is associated with increased morbidity and mortality. Despite intent to relieve congestion, current therapy often fails to relieve orthodema during hospitalization or to prevent recurrence after discharge. Clinical Trial Registration-URL: http://www.clinicaltrials.gov. Unique identifiers: NCT00608491, NCT00577135.
    No preview · Article · Jun 2015 · Circulation Heart Failure

  • No preview · Article · Jun 2015 · Circulation Cardiovascular Quality and Outcomes
  • Lynne Warner Stevenson
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    ABSTRACT: The number of heart transplants performed in the United States was 2177 in 1994 and 2166 in 2014. However, the number of transplant centers has increased, and the criteria for transplants have broadened to include patients 65 years or older, those with a body mass index greater than 30, and more comorbid conditions, such as diabetes mellitus and a history of smoking. As the transplant waiting list has become longer and waiting times have increased, the major route to heart transplants has become deterioration to the most urgent priority status, which accounts for 10% of patients on the waiting list but two-thirds of transplants. Many heart transplant candidates develop life-threatening complications of a ventricular assist device implanted to avert death while waiting. Some affluent patients, however, can afford to temporarily relocate and obtain a transplant in regions where the waiting times are shorter without prior surgery to implant a ventricular assist device. The ethics of allocating hearts for transplant have always recalled the classic lifeboat dilemma of how many people can be allowed to board an already overcrowded lifeboat without sinking the ship and everyone on board. As transplant physicians, we advocate with the best intentions on behalf of our own patients rather than denying transplants to those less likely to benefit. In recognizing our responsibilities as stewards of scarce donor hearts, we should reduce new listings for heart transplants, thus restoring balance to the waiting list and keeping the lifeboat afloat.
    No preview · Article · Jun 2015 · JAMA Internal Medicine

  • No preview · Article · Apr 2015 · The Journal of Heart and Lung Transplantation

  • No preview · Article · Mar 2015 · Journal of the American College of Cardiology
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    ABSTRACT: Background: Though commonly noted in clinical practice, it is unknown if decongestion in acute heart failure (AHF) results in increased serum bicarbonate. Methods and results: For 678 AHF patients in the DOSE-AHF, CARRESS-HF, and ROSE-AHF trials, we assessed change in bicarbonate (baseline to 72-96 hours) by decongestion strategy, and the relationship between bicarbonate change and protocol-defined decongestion. Median baseline bicarbonate was 28 mEq/L. Patients with baseline bicarbonate ≥28 mEq/L had lower EF, worse renal function and higher NT-proBNP than those with baseline bicarbonate <28 mEq/L. There were no differences in bicarbonate change between treatment groups in DOSE-AHF or ROSE-AHF (all p>0.1). In CARRESS-HF, bicarbonate increased with pharmacologic care but decreased with ultrafiltration (median +3.3 vs. -0.9 mEq/L respectively; p<0.001). Bicarbonate change was not associated with successful decongestion (p>0.2 for all trials). Conclusions: In AHF, serum bicarbonate is most commonly elevated in patients with more severe heart failure. Despite being used in clinical practice as an indicator for decongestion, change in serum bicarbonate was not associated with significant decongestion.
    No preview · Article · Mar 2015 · Journal of the American College of Cardiology

  • No preview · Article · Mar 2015 · Journal of the American College of Cardiology
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    ABSTRACT: Patients with left ventricular systolic dysfunction frequently show abnormal coronary vascular function, even in the absence of overt coronary artery disease. Moreover, the severity of vascular dysfunction might be related to the aetiology of cardiomyopathy. We sought to determine the incremental value of assessing coronary vascular dysfunction among patients with ischaemic (ICM) and non-ischaemic (NICM) cardiomyopathy at risk for adverse cardiovascular outcomes. Coronary flow reserve (CFR, stress/rest myocardial blood flow) was quantified in 510 consecutive patients with rest left ventricular ejection fraction (LVEF) ≤45% referred for rest/stress myocardial perfusion PET imaging. The primary end point was a composite of major adverse cardiovascular events (MACE) including cardiac death, heart failure hospitalization, late revascularization, and aborted sudden cardiac death. Median follow-up was 8.2 months. Cox proportional hazards model was used to adjust for clinical variables. The annualized MACE rate was 26.3%. Patients in the lowest two tertiles of CFR (CFR ≤ 1.65) experienced higher MACE rates than those in the highest tertile (32.6 vs. 15.5% per year, respectively, P = 0.004), irrespective of aetiology of cardiomyopathy. Impaired coronary vascular function, as assessed by reduced CFR by PET imaging, is common in patients with both ischaemic and non-ischaemic cardiomyopathy and is associated with MACE. © The Author 2015. Published by Oxford University Press on behalf of the European Society of Cardiology.
    No preview · Article · Feb 2015 · European Heart Journal – Cardiovascular Imaging

Publication Stats

37k Citations
4,694.98 Total Impact Points

Institutions

  • 1999-2015
    • Harvard University
      Cambridge, Massachusetts, United States
  • 1995-2015
    • Brigham and Women's Hospital
      • • Department of Medicine
      • • Division of Cardiac Surgery
      Boston, Massachusetts, United States
  • 1999-2014
    • University of Massachusetts Boston
      Boston, Massachusetts, United States
  • 2013
    • Duke University
      Durham, North Carolina, United States
  • 1996-2013
    • Mayo Clinic - Rochester
      • Department of Cardiovascular Diseases
      Рочестер, Minnesota, United States
  • 2012
    • University of Michigan
      Ann Arbor, Michigan, United States
    • University of Pennsylvania
      • Division of Cardiothoracic Surgery
      Philadelphia, PA, United States
  • 2011
    • Beth Israel Deaconess Medical Center
      • Division of General Medicine and Primary Care
      Boston, MA, United States
  • 1993-2010
    • Harvard Medical School
      • Department of Medicine
      Boston, Massachusetts, United States
  • 2009
    • Partners HealthCare
      Boston, Massachusetts, United States
    • Boston Medical Center
      Boston, Massachusetts, United States
  • 2007
    • Northwestern University
      • Feinberg School of Medicine
      Evanston, Illinois, United States
    • Medical College of Wisconsin
      Milwaukee, Wisconsin, United States
    • Beverly Hospital, Boston MA
      BVY, Massachusetts, United States
  • 2006
    • Silver Spring Networks
      레드우드시티, California, United States
    • Emory University
      Atlanta, Georgia, United States
    • Cleveland Clinic
      • Department of Emergency Medicine
      Cleveland, Ohio, United States
    • Hartford Hospital
      Hartford, Connecticut, United States
  • 2005
    • Blue Water Task Force
      Big Sky, Montana, United States
  • 2004-2005
    • Columbia University
      • International Center for Health Outcomes and Innovative Research
      New York City, New York, United States
    • University of Alabama at Birmingham
      Birmingham, Alabama, United States
  • 2001
    • National Institutes of Health
      베서스다, Maryland, United States
    • University of Texas at Dallas
      Richardson, Texas, United States
  • 1984-1999
    • University of California, Los Angeles
      • • Department of Surgery
      • • Division of Cardiology
      Los Ángeles, California, United States
  • 1998
    • University of California, San Francisco
      • Department of Medicine
      San Francisco, California, United States
  • 1986-1994
    • Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center
      • Department of Medicine
      Torrance, California, United States
  • 1987-1993
    • Harbor-UCLA Medical Center
      Torrance, California, United States
  • 1992
    • CSU Mentor
      • Department of Medicine
      Long Beach, California, United States