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Mobile health applications are becoming increasingly common. Prior work has demonstrated reduced heart failure (HF) hospitalizations with HF disease management programs; however, few of these programs have used tablet computer-based technology. Participants with a diagnosis of HF and at least 1 high risk feature for hospitalization were randomized to either an established telephone-based disease management program or the same disease management program with the addition of remote monitoring of weight, blood pressure, heart rate and symptoms via a tablet computer for 90 days. The primary endpoint was the number of days hospitalized for HF assessed at 90 days. From August 2014 to April 2019, 212 participants from 3 hospitals in Massachusetts were randomized 3:1 to telemonitoring-based HF disease management (n = 159) or telephone-based HF disease management (n = 53) with 98% of individuals in both study groups completing the 90 days of follow-up. There was no significant difference in the number of days hospitalized for HF between the telemonitoring disease management group (0.88 ± 3.28 days per patient-90 days) and the telephone-based disease management group (1.00 ± 2.97 days per patient-90 days); incidence rate ratio 0.82 (95% confidence interval, 0.43-1.58; P =.442). The addition of tablet-based telemonitoring to an established HF telephone-based disease management program did not reduce HF hospitalizations; however, study power was limited [ABSTRACT FROM AUTHOR]

Hodgkin lymphoma is a rare, but highly curative form of cancer, primarily afflicting adolescents and young adults. Despite multiple seminal trials over the past twenty years, there is no single consensus-based treatment approach beyond use of multi-agency chemotherapy with curative intent. The use of radiation continues to be debated in early-stage disease, as part of combined modality treatment, as well as in salvage, as an important form of consolidation. While short-term disease outcomes have varied little across these different approaches across both early and advanced stage disease, the potential risk of severe, longer-term risk has varied considerably. Over the past decade novel therapeutics have been employed in the retrieval setting in preparation to and as consolidation after autologous stem cell transplant. More recently, these novel therapeutics have moved to the frontline setting, initially compared to standard-of-care treatment and later in a direct head-to-head comparison combined with multi-agent chemotherapy. In 2018, we established the HoLISTIC Consortium, bringing together disease and methods experts to develop clinical decision models based on individual patient data to guide providers, patients, and caregivers in decision-making. In this review, we detail the steps we followed to create the master database of individual patient data from patients treated over the past 20 years, using principles of data science. We then describe different methodological approaches we are taking to clinical decision making, beginning with clinical prediction tools at the time of diagnosis, to multi-state models, incorporating treatments and their response. Finally, we describe how simulation modeling can be used to estimate risks of late effects, based on cumulative exposure from frontline and salvage treatment. The resultant database and tools employed are dynamic with the expectation that they will be updated as better and more complete information becomes available. [ABSTRACT FROM AUTHOR]

This study determined the effects of doxorubicin and/or trastuzumab on diastolic function and the relationship between diastolic function and systolic dysfunction. Doxorubicin and trastuzumab can result in left ventricular ejection fraction (LVEF) declines. However, the effects of these therapies on diastolic function remain incompletely defined. In a rigorously phenotyped, longitudinal cohort study of 362 breast cancer participants treated with doxorubicin, doxorubicin followed by trastuzumab, or trastuzumab alone, changes in diastolic function were evaluated using linear models estimated via generalized estimating equations. Associations between baseline and changes in diastolic function with LVEF and longitudinal strain were also determined using generalized estimating equations. The Kaplan-Meier estimator derived the proportion of participants who experienced incident diastolic dysfunction. Cox proportional hazards models estimated the associations between participant characteristics and diastolic dysfunction risk, and between diastolic function and cancer therapy−related cardiac dysfunction risk, defined by an LVEF decline of ≥10% to <50%. Over a median of 2.1 years (interquartile range [IQR]: 1.3 to 4.2 years), participants treated with doxorubicin or doxorubicin followed by trastuzumab demonstrated a persistent worsening in diastolic function, with reductions in the E/A ratio, lateral and septal e′ velocities, and increases in E/e′ (p < 0.01). These changes were not observed with trastuzumab alone. Incident abnormal diastolic function grade occurred in 60% at 1 year, 70% by 2 years, and 80% by 3 years. Abnormal diastolic function grade was associated with a subsequent decrease in LVEF (−2.1%; 95% confidence intervals [CI]: −3.1 to −1.2; p < 0.001) and worsening in longitudinal strain (0.6%; 95% CI: 0.1 to 1.1; p = 0.013) over time. Changes in E/e′ ratio were modestly associated with worsening longitudinal strain (0.1%; 95% CI: 0.0 to 0.2; p = 0.022). A modest, persistent worsening of diastolic function is observed with contemporary breast cancer therapy. Abnormal and worsening diastolic dysfunction is associated with a small risk of subsequent systolic dysfunction. (Cardiotoxicity of Cancer Therapy [CCT]; NCT01173341) [ABSTRACT FROM AUTHOR]

Background: Systolic heart failure (HF) is a low-grade systemic inflammatory state. Neutrophil-lymphocyte ratio (NLR) is a nonspecific inflammatory marker with prognostic value in HF. We aimed to determine the relationship between NLR and mortality during left ventricular assist device (LVAD) support.Methods and Results: We retrospectively reviewed LVAD recipients implanted in the years 2010-2018. NLR was recorded before LVAD implantation and at intervals during LVAD support; pre-LVAD and 90-day LVAD NLRs were compared. Cox proportional hazard models were constructed to study the impact of NLR, both before LVAD implantation and at 90 days with LVAD, on mortality during subsequent LVAD support. Among 301 subjects, the median pre-LVAD NLR was 4.7 (interquartile range 3.0-8.0). Higher pre-LVAD NLR was independently associated with increased mortality during a median 324 days of LVAD support (adjusted hazard ratio [HR] 1.03, 95% confidence interval [CI] 1.01-1.06; P = .012, adjusted for pre-LVAD age, HF etiology, white blood count, hemoglobin, blood urea nitrogen, and sodium). After LVAD implantation, the NLR rose initially and then plateaued lower by day 90. Despite the mean decrease, higher 90-day LVAD NLR remained independently associated with increased mortality (adjusted HR 1.06, 95% CI 1.01-1.13; P = .033, stratified by early infection events).Conclusions: Higher pre-LVAD NLR is independently associated with mortality during LVAD support. NLR improves during LVAD support, but even accounting for early infections, a higher NLR at day 90 remains associated with subsequent mortality. [ABSTRACT FROM AUTHOR]

Older patients with lymphoma are at increased risk for cardiotoxicity with anthracycline-based cancer treatment. Dexrazoxane and liposomal anthracyclines may reduce the risk of heart failure (HF); although, neither clinical practice guidelines nor the FDA endorse the use of these cardioprotective medications in this population due to insufficient evidence. No studies to date have explored the prevalence of "off label" use of these cardioprotective strategies in clinical practice. The Surveillance, Epidemiology and End Results-Medicare (SEER-Medicare) linked database was used to identify individuals with newly diagnosed Diffuse Large B Cell Lymphoma (DLBCL) and Hodgkin's Lymphoma (HL) diagnosed from 2000-2015 who had one year of Medicare Part A and B coverage in the year prior to diagnosis. Exclusion criteria included age <65 years, HMO membership, and lymphoma diagnosed on death certificate. Prevalent and incident HF/cardiomyopathy were defined using International Classification of Diseases codes using a validated algorithm (Go, JAMA 2006). HCPCS codes were used to identify doxorubicin (C9415, J9000), liposomal doxorubicin (J9001, Q2048, Q2049, Q2050) and dexrazoxane (J1190). Among newly diagnosed individuals with DLBCL (n=30,728) and HL (n=3,348), HF in the year prior to diagnosis was present in 14% of the population. Anthracycline-based chemotherapy was used in 34% of DLBCL cases and 52% of HL cases. Radiation was used in 19% of HL and DLBCL cases. In those free from HF at the time of lymphoma diagnosis, incident HF was very common, occurring in 28% of those treated for HL and 26% of those with DLBCL over a median of 2.4 years and 2.7 years, respectively. Among those treated with anthracyclines, liposomal formulations were used in 2.1% of those with DLBCL and 1.2% of those with HL; while dexrazoxane was used in 0.7% of those with DLBCL and 0.8% of those with HL. Despite a high prevalence of HF at the time of lymphoma diagnosis and very high risk of incident HF, cardioprotective medications were rarely used. Randomized trials of cardioprotective strategies are needed to improve cancer and cardiovascular outcomes in this high-risk patient population. [ABSTRACT FROM AUTHOR]

During the novel coronavirus (COVID-19) pandemic, the incidence of cardiovascular hospitalizations has been observed to decrease. The patient behavior, clinician behavior and pathophysiological contributors are currently unclear. We sought to determine if the pattern of heart failure (HF) hospitalizations was the same between 1 Academic Hospital with Advanced HF and Transplant services and 2 Community Hospitals, within a single health system in Massachusetts (MA). The 3 hospitals, Academic/Advanced HF Hospital A, Community Hospital B and Community Hospital C, are all located within 30-mile radius and share many clinical protocols, although HF hospitalizations at Academic/Advanced HF Hospital A include advanced HF therapy referrals and patients listed for heart transplantation. We retrospectively reviewed the weekly adult hospitalizations for HF, defined as patients ≥18 years discharged with a principal diagnosis of HF per ICD-10 coding (I110, I130, I132, I50 subsets) across the 3 hospitals, between January 1 and April 26 in 2019 and 2020. The weekly hospitalization volumes for 2019 and 2020 were displayed as a bar graph, alongside the total MA COVID-19 diagnosis and key dates in the pandemic response, for each hospital. The volume of weekly hospitalizations for HF in March and April 2020 were lower at all 3 hospitals, as compared to 2019 (Figure 1). At Academic/Advanced HF Hospital A, the reduction in weekly HF hospitalizations began in mid-February, prior to the MA 'state of emergency' declaration effective March 11 and the 'stay at home' order effective March 24, 2020. Conversely, at Community Hospitals B and C the reduction in hospitalizations for HF (compared to 2019) occurred closer to the 'stay at home' order. The date on which each hospital formally ramped down non-urgent outpatient visits and procedures occurred first for Academic/Advanced HF Hospital A, but HF hospitalization volume reduction still appeared to precede this announcement. The decrease in hospitalizations for HF during the COVID-19 pandemic began in an Academic/Advanced HF Hospital before the MA 'state of emergency' and 'stay at home' orders, but around the time of the 'state of emergency' order in 2 affiliated Community Hospitals. This observation suggests that the factors driving HF volume during a pandemic may differ across patient populations and hospitals, even within the same region. [ABSTRACT FROM AUTHOR]

While preoperative hemodynamic risk factors associated with early right heart failure (RHF) following left ventricular assist device (LVAD) surgery are well-established, the relationship between postoperative hemodynamic status and subsequent outcomes remains poorly defined. We analyzed adult CF-LVAD patients from the STS-INTERMACS registry surviving at least 3 months without evidence of early RHF and with hemodynamic data available at 3 months after LVAD implant. The association between metrics of RV afterload and function and the subsequent risk of death, right heart failure (RHF), gastrointestinal bleeding (GIB), or stroke were assessed using multivariable Cox proportional hazards modeling. Among 1,050 patients with available 3-month hemodynamics, pulmonary hypertension was common, with 585 (55.7%) having mPAP ≥ 20 mm Hg and 164 (15.6%) having PVR ≥ 3 WU. Pulmonary artery pulsatility index (PAPi, HR 0.62 per log-increase for values < 3, 95% CI 0.43-0.89) and PVR (HR 1.19 per 1 WU-increase for values > 1.5 WU, 95% CI 1.03-1.38) were independently associated with the composite of death or RHF. Postoperative RAP (HR 1.18 per 5 mm Hg increase, 95% CI 1.04-1.33), RAP:PCWP (HR 1.46 per log-increase, 95% CI 1.12-1.91), and PAPi (HR 0.76 per log-increase, 95% CI 0.61-0.95) were each associated with GIB risk. Postoperative hemodynamics was not associated with stroke risk. Hemodynamic metrics of postoperative RV dysfunction and elevated RV afterload are independently associated with RHF, mortality and GIB. Whether strategies targeting postoperative optimization of RV function and afterload can reduce the burden of these adverse events requires prospective study. [ABSTRACT FROM AUTHOR]