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Introduction Functional status assessment in the HF population has typically relied on self-reported questionnaires like Kansas City Cardiomyopathy Questionnaire (KCCQ). Since 2011, Cleveland Clinic physical therapists have administered an objective, validated measure of physical function—the Activity Measure for Post-Acute Care (PAC) ”6-Clicks”. 6-Clicks assesses ability to turn in bed, sit, transfer from bed to chair, stand, walk, eat, dress, bathe, perform personal care and use the bathroom. Scores range from 6 to 24, with higher scores representing greater functional independence. We characterized the association between 6-clicks score and PAC disposition (home, home care, or SNF) in patients admitted for HF whose relative functional status was moderate (score >12) or better. Establishing if an objective functional status assessment is associated with PAC disposition in HF patients has not been previously described. Understanding factors driving facility use post-discharge may have implications for length of stay, patient satisfaction, health system costs, external quality measures, and efforts to decrease facility usage in the COVID era. Methods/Results In 2019, 772 patients with CHF-DRGs were admitted to the Cleveland Clinic hospitals across Ohio. Patients with 6-clicks Conclusion Lower 6-clicks functional status scores were associated with discharge to SNF in HF patients. Living alone had a trend toward association with facility use but did not meet statistical significance. Given significant overlap in functional status across disposition destinations, however, other factors beyond functional status including family support factor into discharge disposition.

Purpose PIONEER-HF established the safety of the angiotensin receptor-neprilysin inhibitor (ARNI), sacubitril-valsartan (S/V), in patients hospitalized with acute decompensated heart failure after achieving hemodynamic stability. We have previously shown that transitioning patients in ADHF with low cardiac output directly from intravenous (IV) vasoactive (i.e. vasodilators or inotropes) drugs to ARNI can be done safely with tolerance to one-month follow-up. Here we further characterize the acute hemodynamic impact of ARNI therapy after patients have been optimized on IV vasoactive therapy. Methods A single-center, retrospective analysis of all patients with HFrEF (EF Conclusions ICU patients can be successfully bridged from vasoactive IV therapy to oral ARNI with sustained improvement in cardiac index garnered from vasoactive agents. We also observed improvement in PAPI along with maintenance of LV/RV unloading with ARNI. These encouraging findings merit prospective validation of ARNI compared to more commonly used oral vasodilators in ICU care.

Purpose PIONEER-HF established the safety of the angiotensin receptor-neprilysin inhibitor (ARNI), sacubitril-valsartan (S/V), in patients hospitalized with acute decompensated heart failure after achieving hemodynamic stability. We have previously shown that transitioning patients in cardiogenic shock directly from intravenous (IV) vasoactive (i.e. vasodilators or inotropes) drugs to S/V can be done safely with tolerance to one-month follow-up. Here we further characterize the hemodynamic impact of S/V after patients have been optimized on vasoactive therapy. Methods A single-center, retrospective analysis of all patients with HFrEF (EF Results Twenty-two patients with HFreF and cardiac index below 2.2 L/min/m2 were admitted to the CICU and newly initiated on S/V. Table 1a contains baseline characteristics and vasoactive therapy given. All patients were weaned off vasoactive medications prior to transfer out of CICU. Patients maintained their significant hemodynamic improvement on transition from IV to oral vasoactive therapy. There was an increase in Pulmonary Artery Pulsatility index (PAPi) with S/V therapy (Table 1b). Patients who did not tolerate ARNI initiation had lower filling pressures and systolic blood pressure compared to patients who tolerated ARNI initiation. Seventeen patients were discharged home on S/V, and 94% remained on S/V one-month in follow-up. Conclusion ICU patients can be successfully bridged from vasoactive IV therapy to oral S/V with sustained hemodynamic improvement garnered from vasoactive agents. We also observed improvement in PAPi with S/V compared to both admission and vasoactive therapy. These encouraging findings merit further prospective study.

The benefits of angiotensin receptor-neprilysin inhibitor (ARNI) in patients with heart failure with reduced ejection fraction (HFrEF) are well established [(1)][1]. The majority of patients with HFrEF are receiving suboptimal guideline-directed medical therapy (GDMT). Data from the CHAMP-HF (Change

Introduction Sacubitril/valsartan (S/V) is superior to enalapril in reducing mortality and morbidity in patients with chronic stable heart failure with reduced ejection fraction (HFrEF). The goal of this investigation was to determine if S/V could be used safely as an oral vasodilator when weaning intravenous vasoactive therapies. Methods Invasive hemodynamic data was prospectively collected from ten consecutive patients with Stage D HFrEF admitted to the heart failure intensive care unit (HF-ICU) for treatment of acute decompensated heart failure. All patients were admitted for pulmonary artery catheter hemodynamic guided therapy and were initiated on S/V. Results Ten patients were included in the cohort and were on either intravenous inotropes n=3 or sodium nitroprusside (SNP) n=7. Mean dose of SNP was 151 mcg/min, mean dose for dobutamine was 5 mcg/kg/min and milrinone dose was 0.5 mcg/kg/min. Mean age was 50 years old, with 4 females and 6 males. Three patients with ischemic cardiomyopathy, 7 non-ischemic cardiomyopathy. All patients were successfully weaned from inotropes or SNP and tolerated S/V initiation. Average mean arterial pressure of the cohort decreased from 88.3 to 80.6 mmHg (9% reduction), right atrial pressure decreased from 15.6 to 5 mmHg (70% reduction), mean pulmonary artery pressure decreased from 43.6 to 27.3 mmHg (37% reduction), pulmonary capillary wedge pressure decreased from 28.4 to 14.7 mmHg (48% reduction), mean cardiac index increased from 1.7 to 2.56 l/min/m2 (51% increase) and mixed venous saturation increased from 52.6 to 67.2% (22% increase). The detailed hemodynamic results for each patient are summarized in Table 1. S/V was well tolerated and hemodynamics were stable after weaning IV therapy. Conclusion Patients with cardiogenic shock tolerated initiation of S/V and subsequent successful weaning of intravenous vasodilator or inotropic therapy. These preliminary novel hemodynamic observations suggest S/V may be initiated safely in ICU patients and facilitate weaning from intravenous therapies.

Introduction A recent randomized clinical study established the safety of the angiotensin receptor-neprilysin inhibitor (ARNI), sacubitril-valsartan (S/V), in patients hospitalized with acute decompensated heart failure after achieving hemodynamic stability. Transitioning patients in cardiogenic shock managed with pulmonary artery catheters directly from intravenous vasoactive (i.e. vasodilators or inotropes) drugs to S/V represents a potentially novel use for ARNIs. The tolerability and hemodynamic characteristics of S/V in patients with cardiogenic shock has not been previously established. Methods A single-center, retrospective analysis of all patients with heart failure and a reduced ejection fraction (HFrEF) (EF Results Twenty-two patients in the CICUs with HFrEF were started on S/V. The baseline characteristics, pertinent lab values, and hemodynamic profile (CI, SVR), are presented (Image 1). Ninety-five percent (n=21) of patients were on either of sodium nitroprusside, milrinone, dobutamine, or a combination these agents, at the time of initiation. Seventy-seven percent (n=17/22) patients were discharged on S/V with improved hemodynamics (Image 1,2). Hypotension was the most common reason for discontinuation (n=4) however one patient had both acute kidney injury and hypotension (n=1); no patients had hyperkalemia or death (n=0) (Image 2). Two of five intolerant patients were initiated on moderate (49-51) dose S/V. Conclusions The novel use S/V as oral vasodilator therapy in patients with cardiogenic shock shows favorable hemodynamic impact and tolerability. Long term tolerability and outcomes are required.