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Background This study sought to evaluate the 15‐year national utilization, trends, predictors, disparities, and outcomes of palliative care services ( PCS ) use in cardiogenic shock complicating acute myocardial infarction. Methods and Results A retrospective cohort from January 1, 2000 through December 31, 2014 was analyzed using the National Inpatient Sample database. Administrative codes for acute myocardial infarction–cardiogenic shock and PCS were used to identify eligible admissions. The primary outcomes were the frequency, utilization trends, and predictors of PCS . Secondary outcomes included in‐hospital mortality and resources utilization. Multivariable regression and propensity‐matching analyses were used to control for confounding. In this 15‐year period, there were 444 253 acute myocardial infarction–cardiogenic shock admissions, of which 4.5% received PCS . The cohort receiving PCS was older, of white race, female sex, and with higher comorbidity and acute organ failure. The PCS cohort received fewer cardiac procedures, but more noncardiac organ support therapies. Older age, female sex, white race, higher comorbidity, higher socioeconomic status, admission to a larger hospital, and admission after 2008 were independent predictors of PCS use. Use of PCS was independently associated with higher in‐hospital mortality (odds ratio 6.59 [95% CI 6.37–6.83]; P PCS use had >2‐fold higher in‐hospital mortality, 12‐fold higher use of do‐not‐resuscitate status, lesser in‐hospital resource utilization, and fewer discharges to home. Similar findings were observed in the propensity‐matched cohort. Conclusions PCS use in patients with acute myocardial infarction–cardiogenic shock is low, though there is a trend towards increased adoption. There are significant patient and hospital‐specific disparities in the utilization of PCS .

Since their initial clinical demonstration in 1980, implantable cardioverter–defibrillators (ICDs) have prolonged countless lives with successful treatment of sudden cardiac arrest.1 No other therapy has proved as effective in preventing death from ventricular arrhythmias, and important advances in ICD technology continue to improve outcomes for well-selected patients.2 Although indicated for a wide range of inherited and acquired conditions,3 ICDs are predominantly placed in older patients with left ventricular systolic dysfunction and either previous myocardial infarction or congestive heart failure.4 In the United States alone, >50 000 ICDs are placed annually in patients aged > 65 years, and nearly 500 000 more may meet current guidelines for device implantation.5 However, decision making for older patients considering ICD implantation is particularly challenging. Subjects in the landmark trials had average ages in the 60s, and thus the survival benefits of ICDs in older age groups is less well-established.6 In addition, compared with the younger participants in most clinical trials, older adults have a lower ratio of arrhythmic death to nonarrhythmic death because of competing risks for mortality, resulting in a potentially lower absolute risk reduction. At the same time, living and eventually dying with an ICD introduces potential risks, including a lower quality of life (QoL), hospitalizations, and potential suffering at the end of life.7 A rigorous consideration of the benefits, risks, and ongoing care surrounding ICD use in older patients is long overdue. On April 22, 2014, we convened a conference of multidisciplinary experts in cardiac electrophysiology, heart failure, geriatrics, ethics, and palliative care in Boston, supported by the Hartford Change AGEnts and Paul B. Beeson Career Development Award programs, and the Hebrew SeniorLife Institute for Aging Research. The objectives of the conference were (1) to review what is currently known about ICD use in …

Background— Patients undergo major physical and psychological changes after implantation of a left ventricular assist device as destination therapy (DT). We sought to qualitatively study outcomes and attitudes of patients after DT. Methods and Results— Ambulatory outpatients with DT at our institution were invited to be interviewed between June and August 2011. In-person interviews were audio-recorded, transcribed, and analyzed qualitatively using thematic analysis. The study included 12 patients (11 men) from the Midwestern United States with a median age of 71.5 years (range, 33–78 years). Interviews were conducted at a median (range) time of 1.37 (0.43–5.04) years after DT implantation. Most patients were white (n=11), married (n=10), and Christian (n=10). We identified 6 themes commonly discussed by the interviewees: preparedness planning, new lease on life, optimizing support networks, systemic limitations, reflections on time, and communication matters. Analysis revealed that most patients saw DT as their only choice, despite other alternatives. Conclusions— Ambulatory patients reported varied experiences after DT but commonly reported gratitude for improved functional status and a perception of improved symptom burden. Recommendations for improving post-DT care include developing patient support systems, systematizing education for community providers, and expanding respite services.

Background— Little is known about the resuscitation preferences of patients with heart failure, how they may change over the course of the disease, and their association with mortality. Methods and Results— We enrolled consecutive Southeastern Minnesota residents with heart failure from October 2007 through September 2011 into a longitudinal study. Information on resuscitation preferences (Full Code or do-not-resuscitate [DNR]) was obtained from medical records through April 1, 2013. Of 608 patients enrolled, 237 died during follow-up. At enrollment, most patients (73.4%) were Full Code, whereas at death, most (78.5%) were DNR. The independent predictors of DNR status at enrollment were advanced age, chronic obstructive pulmonary disease, previous malignancy, and decreased mobility. Patients who were DNR were at increased risk of death (unadjusted hazard ratio, 2.03; 95% confidence interval, 1.48–2.73; P P =0.83). Of 481 patients who were Full Code during follow-up, 22 (4.6%) received cardiopulmonary resuscitation for an in-hospital cardiac arrest. Eight patients survived to hospital discharge; only 2 (9.1% of those receiving cardiopulmonary resuscitation) made a complete recovery and returned home. The median time from a final decision to be DNR until death was only 37 (7,70) days. Conclusions— The resuscitation preferences of patients with heart failure seem to be driven by the decline in clinical status that often accompanies advanced age and multimorbidity. Furthermore, these data suggest that electing DNR status does not independently affect a patient’s risk of death.

Objectives Patients with heart failure may experience psychiatric disorders for which electroconvulsive therapy (ECT) is indicated. Little is known, however, about the safety of ECT in these patients. We assessed the safety of ECT in patients with a history of heart failure and decreased left ventricular systolic heart function. Methods We conducted a retrospective review of the medical records of 35 patients with a history of heart failure and reduced left ventricular systolic heart function who underwent ECT at Mayo Clinic in Rochester, Minnesota, between January 1995 and December 2009. Results Of the 35 patients, 18 (51%) were women. The median age was 77 years (range, 54-92 years). The median left ventricular ejection fraction was 30% (range, 15%-40%). The 35 patients underwent 513 ECT sessions (median number of sessions per patient, 10; range, 1-44). The 35 patients tolerated ECT well. No patient died or experienced decompensated heart failure, myocardial ischemia, or myocardial infarction during or within 24 hours after an ECT session. Prophylactic intravenous β-blockers were given to patients who, during previous ECT sessions, had marked hypertension (eg, systolic blood pressure >180-200 mm Hg) or a heart rate greater than 100 beats per minute; overall, this prophylaxis was used in 26 patients during 413 ECT sessions (80% of the total number of ECT sessions). Three patients experienced temporary, non-life-threatening cardiac arrhythmias. Conclusions Electroconvulsive therapy was safe in 35 patients with a history of heart failure and decreased left ventricular systolic heart function treated at our institution.

Rectus sheath hematoma (RSH) is an uncommon condition characterized by abdominal pain and an abdominal wall mass. We reviewed the clinical features, treatment, and outcomes of 126 patients treated for RSH at Mayo Clinic from January 1, 1992, to December 31, 2002. Most patients (64%) were women and the mean +/- SD age was 67.9 +/- 16.5 years. Most patients (69%) were on some form of anticoagulation therapy. The mean international normalized ratio was 2.6 +/- 2.4, and mean activated partial thromboplastin time was 64.2 +/- 42.7 seconds. No patients were pregnant or had a peritoneal dialysis catheter at the time of diagnosis. Approximately half of the patients (48%) had nonsurgical abdominal trauma around the time of diagnosis, with 37 patients (29%) having a cough. The most common presenting signs and symptoms were abdominal pain (84%) and an abdominal wall mass (63%). CT of the abdomen and pelvis was the most commonly used method to establish the diagnosis (83%). Most patients (86%) were successfully treated with symptom management and blood transfusion. Ten patients (7.9%) underwent surgery or endovascular embolization of bleeding vessels, and 2 patients (1.6%) died as a result of RSH bleeding. Although RSH is rarely fatal, the clinician should be aware of important risk factors that lead to RSH including female sex, older age, anticoagulation therapy, and cough or other abdominal trauma. Rapid diagnosis with directed history, physical examination, and CT of the abdomen and pelvis may help decrease unnecessary laparotomy and lead to better triage of patients who present with RSH.

The liver is a common site of amyloid deposition in primary systemic amyloidosis. We reviewed the clinical features and natural history of patients with primary systemic amyloidosis and biopsy-proven hepatic involvement who were evaluated at Mayo Clinic from January 1, 1975, to December 31, 1997. The median age of the study group (68 men; 30 women) was 58.5 years. Seventy-one patients (72%) had involuntary weight loss. Hepatomegaly was found in 79 patients (81%). Eighty-two patients (89%) had proteinuria, and 81 patients (86%) had elevated serum alkaline phosphatase levels. Seventy-six patients (83%) had either a serum or urine monoclonal protein. Before liver biopsy, clinicians considered amyloidosis in the differential diagnosis for only 14 patients (26%). None of our patients experienced hepatic rupture or death due to liver biopsy, and only 4 (4%) bled after liver biopsy. The median survival of the 98 patients was 8.5 months. Predictors of a poor prognosis were congestive heart failure, elevated concentrations of bilirubin, and a platelet count greater than 500 x 109/L. In conclusion, clinicians should consider the diagnosis of primary hepatic amyloidosis in patients who present with involuntary weight loss or hepatomegaly. Other clues to the diagnosis include an unexplained elevated serum alkaline phosphatase level, proteinuria, and evidence for hyposplenism (for example, Howell-Jolly bodies on peripheral blood smear). Liver biopsy was safe. Some patients benefit from systemic chemotherapy.

Electroconvulsive therapy (ECT) is often performed for patients with psychiatric disorders who also have diabetes mellitus. Some research has suggested that the course of ECT treatments does not have a consistent effect on blood glucose, but little data exist to inform the clinician about the effects of individual ECT treatments on blood glucose. In this study, 18 patients with type 2 diabetes mellitus were treated with ECT for severe depressive illness. For each patient, a fingerstick blood glucose was routinely obtained before and approximately 20 minutes after each ECT treatment. We found a mean rise of blood glucose after each treatment of approximately 9%, similar to the mean rise of blood glucose among nondiabetic patients undergoing ECT found in a previous study. There were no cases of clinically significant rise or fall in blood glucose. We provide recommendations for management of diabetics during ECT.

Background: Heart failure (HF) has an overall poor prognosis, with only half of patients surviving more than 5 years after diagnosis. Although it is recommended that all patients with HF have advance directives (ADs) in place before the end of life is imminent, the use of ADs in these patients has not been well studied. Methods: We prospectively enrolled all Olmsted County residents presenting with active HF from October 2007 through October 2011 into a longitudinal community cohort study which included an echocardiogram and administration of health status questionnaires at enrollment. Information from ADs completed prior to enrollment was manually abstracted from the patient’s medical record. Results: A total of 608 patients were enrolled during the study period (mean age 74.0 years, 54.9% male, 49.9% with preserved EF [EF≥50%], 65.3% NYHA functional class 3 or 4). Mortality was high; 164 (27.0%) patients died after a mean follow-up of 1.8 years with estimated 1-year mortality of 14.3%. At the time of enrollment, only 249 (41.0%) patients had ADs, and they were completed an average of 3.3 years prior. Although most ADs appointed a proxy decision-maker (91.1%), less than half addressed patient wishes regarding use of cardiopulmonary resuscitation (41.4%), mechanical ventilation (38.7%), administration of artificial nutrition (38.6%), or hemodialysis (10.0%) at the end of life. AD use was more common in older individuals (p Conclusions: Despite a high mortality rate, over half of community patients with HF do not have ADs, and existing AD fail to address important medical decisions common at the end of life. Further work is needed to identify potential barriers to AD use in HF patients, and to determine whether their use has any impact on patient outcomes, including end of life resource utilization.