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The Treatment of Heart Failure, Then and Now

Hello. I am Dr. Ileana Piña, Associate Chief of Cardiology at Montefiore Einstein Vascular and Cardiac Center in the Bronx, New York.

I am in Washington, DC, where the weather hasn't been great but the meeting of the American College of Cardiology has been fabulous. There is a tremendous amount of energy; you can feel it in the hallways of the convention center and in the exhibit hall.

Let me talk to you about a session from yesterday that I particularly liked. In this session, some young investigators talked about getting to the nitty-gritty of acute heart failure (HF). There is a lot of interest in acute HF, because if you look at how we treat it today and how we treated it 15 years ago, not very much has changed. We are always waiting for that next drug or device that is going to help the multitude of patients with HF who come in to the hospital short of breath, fatigued, and decompensated.

Two Different Presentations of HF

A couple of studies looked at the presentation of the patient, and one in particular from the United Kingdom and John Cleland's group[1] divided the patients into those who came in very short of breath and dyspneic (the acute pulmonary edema-like patient) and those who came in with more chronic volume overload that had developed over a longer period, so that the shortness of breath wasn't as severe. Are these 2 groups different?

They will both probably receive similar treatment, but there is a certain urgency about the patient who is severely short of breath, and you have to make that patient better more rapidly. In fact, those patients had better outcomes than the patients who came in with the more chronic accumulation of fluid.

We wonder whether some of our acute HF trials have not met their endpoints because we are dealing with 2 very different populations and presentations, and this could apply to HF with preserved ejection fraction -- in other words, HF with reduced ejection fraction.

Length of Stay and Cost

The other interesting abstract, presented by Gregg Fonarow,[2] had to do with length of stay. In the United States, the average length of stay for a Medicare patient is 4.5 days, and hospitals have been trying to shorten that length of stay. To our surprise, the 30-day readmission rate has gone up as the length of stay has shortened. This study looked at the cost of hospitalization. They divided up the patients into those who had been there for fewer than 4 days, 4-7 days, and longer than 7 days. The difference in cost for those who had been there for more than a week was truly astronomical, at least 3 times higher than the patients who had been there for 4-7 days.

We intuitively believe that all of the upfront costs in the hospital are incurred in the first few days, and that the last few days don't matter as much because the costs have gone down. You are finished with acute intravenous therapies, you provided them with all the necessary monitoring. That is not the case, however. These data may help us to stratify patients from a systems standpoint to look at the very high-end users, who in my own institution may be the patients who have had complications from an invasive procedure, or became septic, and are way up on the cost scale. For better triage, take a look at this paper.

Bendopnea

I want to finish today with a very interesting paper from JACC: Heart Failure, which is one of the "baby journals," as they are called, of the Journal of the American College of Cardiology. Chris O'Connor is the editor and he is doing a superb job. There is an article with "bendopnea" in the title.[3] Bendopnea is when a person bends over to tie his or her shoes and becomes short of breath. Those of us who have taken care of patients with HF for a long time definitely know about bendopnea (even though we never called it that) because it is a classic symptom in patients whose filling pressures are already high. The patients will tell you that they cannot bend down and tie their shoelaces because they become extremely short of breath, feel chest tightness, or feel dizzy.

The group of investigators from Mark Drazner's group[3] in Texas looked at a group of patients and measured their filling pressures. The patients who had bendopnea were those who already had elevated central venous pressures, and lowering their heads and bending over increased that central venous pressure. As Lynn Stevenson [and Anju Nohria] wrote in a very beautiful editorial,[4] these new observations are never obsolete.

Thank you for joining me today. Please read all of the excerpts from the American College of Cardiology meeting, and in the future I will report more of the late-breaking clinical trials when we have the full data. This is Ileana Piña.

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