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Background: Reasons for suboptimal prescribing for heart failure with reduced ejection fraction (HFrEF) have been identified, but it is unclear if they remain relevant with recent advances in healthcare delivery and technologies. This study aimed to identify and understand current clinician‐perceived challenges to prescribing guideline‐directed HFrEF medications. Methods: We conducted content analysis methodology, including interviews and member‐checking focus groups with primary care and cardiology clinicians. Interview guides were informed by the Cabana Framework. Results: We conducted interviews with 33 clinicians (13 cardiology specialists, 22 physicians) and member checking with 10 of these. We identified four levels of challenges from the clinician perspective. Clinician level challenges included misconceptions about guideline recommendations, clinician assumptions (e.g., drug cost or affordability), and clinical inertia. Patient–clinician level challenges included misalignment of priorities and insufficient communication. Clinician–clinician level challenges were primarily between generalists and specialists, including lack of role clarity, competing priorities of providing focused versus holistic care, and contrasting confidence regarding safety of newer drugs. Policy and system/organisation level challenges included insufficient access to timely/reliable patient data, and unintended care gaps for medications without financially incentivized metrics. Conclusion: This study presents current challenges faced by cardiology and primary care which can be used to strategically design interventions to improve guideline‐directed care for HFrEF. The findings support the persistence of many challenges and also sheds light on new challenges. New challenges identified include conflicting perspectives between generalists and specialists, hesitancy to prescribe newer medications due to safety concerns, and unintended consequences related to value‐based reimbursement metrics for select medications. [ABSTRACT FROM AUTHOR]

The role of palliative care for patients with heart failure (HF) is discussed in both most recent HF guidelines, the 2021 ESC guideline and the 2022 AHA/ACC/HFSA guideline. This review compares the definitions, concepts and specific recommendations regarding palliative care for patients with HF in these two guidelines. Both HF guidelines define palliative care as a multidisciplinary approach aimed at alleviating physical, psychological and spiritual distress of patients and caregivers. Both agree emphatically on the importance of palliative care across all stages of HF with integration early in the illness trajectory. Also, the guidelines concur that palliative care should include symptom management, communication about prognosis and life‐sustaining therapies, as well as advance care planning. Despite this consensus, only the AHA/ACC/HFSA guideline gives official recommendations on the provision of palliative care. Moreover, the AHA/ACC/HFSA guideline advocates for a needs‐based approach to palliative care allocation while the ESC guideline ties palliative care closely to advanced HF and end‐of‐life care. The ESC guideline highlights the need for regular symptom assessment and provides detailed guidance on symptom management. The AHA/ACC/HFSA guideline elaborates further on shared decision‐making, caregiver and bereavement support, as well as hospice care, and distinguishes between primary palliative care (provided by all clinicians) and secondary (specialty‐level) palliative care. Although there is strong agreement on the importance and components of palliative care for patients with HF, there are nuanced differences between the two HF guidelines. Most notably, only the AHA/ACC/HFSA guideline issues recommendations for the provision of palliative care. [ABSTRACT FROM AUTHOR]

Aims: Sex differences in long‐term outcomes following hospitalization for heart failure (HF) across ejection fraction (EF) subtypes are not well described. In this study, we evaluated the risk of mortality and rehospitalization among males and females across the spectrum of EF over 5 years of follow‐up following an index HF hospitalization event. Methods and results: Patients hospitalized with HF between 1 January 2006 and 31 December 2014 from the American Heart Association's Get With The Guidelines‐Heart Failure registry with available 5‐year follow‐up using Medicare Part A claims data were included. The association between sex and risk of mortality and readmission over a 5‐year follow‐up period for each HF subtype (HF with reduced EF [HFrEF, EF ≤40%], HF with mildly reduced EF [HFmrEF, EF 41–49%], and HF with preserved EF [HFpEF, EF >50%]) was assessed using adjusted Cox models. The effect modification by the HF subtype for the association between sex and outcomes was assessed by including multiplicative interaction terms in the models. A total of 155 670 patients (median age: 81 years, 53.4% female) were included. Over 5‐year follow‐up, males and females had comparably poor survival post‐discharge; however, females (vs. males) had greater years of survival lost to HF compared with the median age‐ and sex‐matched US population (HFpEF: 17.0 vs. 14.6 years; HFrEF: 17.3 vs. 15.1 years; HFmrEF: 17.7 vs. 14.6 years for age group 65‐69 years). In adjusted analysis, females (vs. males) had a lower risk of 5‐year mortality (adjusted hazard ratio [aHR] 0.89, 95% confidence interval [CI] 0.87–0.90, p < 0.0001), and the risk difference was most pronounced among patients with HFrEF (aHR 0.87, 95% CI 0.85–0.89; pinteraction[sex*HF subtype] = 0.04). Females (vs. males) had a higher adjusted risk of HF readmission over 5‐year follow‐up (aHR 1.06, 95% CI 1.04–1.08, p < 0.0001), with the risk difference most pronounced among patients with HFpEF (aHR 1.11, 95% CI 1.07–1.14; pinteraction[sex*HF subtype] = 0.001). Conclusions: While females (vs. males) had lower adjusted mortality, females experienced a significantly greater loss in survival time than the median age‐ and sex‐matched US population and had a greater risk of rehospitalization over 5 years following HF hospitalization. [ABSTRACT FROM AUTHOR]

Aims: To optimize guideline‐directed medical therapy for heart failure, patients may require the initiation of multiple neurohormonal antagonists (NHAs) during and following hospitalization. The safety of this approach for older adults is not well established. Methods and results: We conducted an observational cohort study of 207 223 Medicare beneficiaries discharged home following a hospitalization for heart failure with reduced ejection fraction (HFrEF) (2008–2015). We performed Cox proportional hazards regression to examine the association between the count of NHAs initiated within 90 days of hospital discharge (as a time‐varying exposure) and all‐cause mortality, all‐cause rehospitalization, and fall‐related adverse events over the 90 day period following hospitalization. We calculated inverse probability‐weighted hazard ratios (IPW‐HRs) with 95% confidence intervals (CIs) comparing initiation of 1, 2, or 3 NHAs vs. 0. The IPW‐HRs for mortality were 0.80 [95% CI (0.78–0.83)] for 1 NHA, 0.70 [95% CI (0.66–0.75)] for 2, and 0.94 [95% CI (0.83–1.06)] for 3. The IPW‐HRs for readmission were 0.95 [95% CI (0.93–0.96)] for 1 NHA, 0.89 [95% CI (0.86–0.91)] for 2, and 0.96 [95% CI (0.90–1.02)] for 3. The IPW‐HRs for fall‐related adverse events were 1.13 [95% CI (1.10–1.15)] for 1 NHA, 1.25 [95% CI (1.21–1.30)] for 2, and 1.64 [95% CI (1.54–1.76)] for 3. Conclusions: Initiating 1–2 NHAs among older adults within 90 days of HFrEF hospitalization was associated with lower mortality and lower readmission. However, initiating 3 NHAs was not associated with reduced mortality or readmission and was associated with a significant risk for fall‐related adverse events. [ABSTRACT FROM AUTHOR]

Heart failure (HF) is a complex syndrome that affects mortality/morbidity and acts at different levels in the patient's life, resulting in a drastic impairment in multiple aspects of daily activities (e.g. physical, mental/emotional, and social) and leading to a reduction in quality of life. The definition of disease status and symptom severity has been traditionally based on the physician assessment, while the patient's experience of disease has been long overlooked. The active participation of patients in their own care is necessary to better understand the perception of disease and the multiple aspects of life affected, and to improve adherence to treatments. Patient‐reported outcomes (PROs) aim to switch traditional care to a more patient‐centred approach. Although PROs demonstrated precision in the evaluation of disease status and have a good association with prognosis in several randomized controlled trials, their implementation into clinical practice is limited. This review discusses the modalities of use of PROs in HF, summarizes the most largely adopted PROs in HF care, and provides an overview on the application of PROs in trials and the potential for their transition to clinical practice. By discussing the advantages and the disadvantages of their use, the reasons limiting their application in daily clinical routine, and the strategies that may promote their implementation, this review aims to foster the systematic integration of the patient's standpoint in HF care. [ABSTRACT FROM AUTHOR]

Background: Using DAs for preference‐sensitive decisions is an evidence‐based way to improve patient‐centered decisions. Reimbursement mandates have increased the need for DAs in ICD care, although none have been formally evaluated. The objectives were to develop and pilot implantable cardioverter‐defibrillator (ICD) decision aids (DAs) for patients considering primary prevention ICDs. Methods: Development Phase: An expert panel, including patients and physicians, iteratively developed four DAs: a one‐page Option GridTM conversation aid, a four‐page in‐depth paper tool, a 17‐minute video, and an interactive website. Trial Phase: At three sites, patients with heart failure who were eligible for primary prevention ICDs were randomly assigned 2:1 to intervention (received DAs) or control (usual care). We conducted a mixed‐methods evaluation exploring acceptability and feasibility. Results: Twenty‐one eligible patients enrolled (15 intervention). Most intervention participants found the DAs to be unbiased (67%), helpful (89%), and would recommend them to others (100%). The pilot was feasible at all sites; however, using clinic staff to identify eligible patients was more efficient than chart review. Although the main goals were to measure acceptability and feasibility, intervention participants trended towards increased concordance between longevity values and ICD decisions (71% concordant vs. 29%, p =.06). Participants preferred the in‐depth paper tool and video DAs. Access to a nurse during the decision‐making window encouraged questions and improved participant‐perceived confidence. Conclusions: Participants felt the DAs provided helpful, balanced information that they would recommend to other patients. Further exploration of this larger context of DA use and strategies to promote independent use related to electrophysiology (EP) visits are needed. [ABSTRACT FROM AUTHOR]

Co‐operation in the management of shared fish stocks is often necessary to achieve sustainability and reduce uncertainty. The United States of America (USA) and Mexico share a number of fish stocks and marine ecosystems, while there is some binational co‐operation in scientific research, unilateral management decisions are generally the rule. We present a case study using the giant sea bass (Stereolepis gigas, Polyprionidae) to highlight how these management and research asymmetries can skew national perceptions of population status for a fully transboundary species. Scientific publications and annual funding related to giant sea bass are 7x and 25x higher in the USA, respectively, despite the fact that 73% of the species' range occurs in Mexico. Conversely, annual fishery production and consumptive value of giant sea bass in Mexico are 19x and 3.5x higher than in the USA, respectively, while the non‐consumptive value related to dive ecotourism is 76x higher in the USA. These asymmetries have generated a distorted view of the population status of the giant sea bass across its entire range. This and other factors related to historical fishery dynamics and policy must be accounted for when assessing population status, and subsequent appropriate management responses, across geopolitical boundaries. [ABSTRACT FROM AUTHOR]

Background: CMS reimbursement guidelines for implantable cardioverter‐defibrillators (ICDs) include mandated shared decision making (SDM), but without any manner of assessing the quality of decisions made. We developed and tested a scale meant to assess patients' knowledge of and preferences specific to ICDs. Such a tool would assess these constructs in the clinical environment, targeting resources and support for patients considering a primary prevention ICD. Methods: Development of the ICD decision quality (ICD‐DQ) scale included (1) item creation, (2) content validation using surveys of patients (n = 23) and clinicians (n = 31), and (3) examination of validity and reliability using a survey of patients who previously received an ICD (n = 295, response rate = 72%). Results: The final scale consists of 12 knowledge and 8 preference items. With respect to content validity, clinician and patient respondents agreed on the importance of 19 of 24 candidate knowledge items (79%), and 9 of 11 treatment preference items (81%). Knowledge items exhibited moderate internal validity (α = 0.62, 1 factor), strong test‐retest reliability (mean % correct at first administration = 59%, 62% at follow‐up, P >.1) and discriminant validity (59% correct for patients, 93% among cardiologists). Short versions of the ICD‐DQ were developed for clinical settings, the scores from both of which correlated with the long version in this cohort (11‐item (r = 0.90) and a 5‐item (r = 0.75)). Conclusions: : The ICD‐DQ fills a critical gap in measuring the quality of patients' ICD decisions. They may be used to evaluate the effectiveness of patient decision aids or the quality of SDM in clinical practice. [ABSTRACT FROM AUTHOR]

Current pharmacological therapies for heart failure with reduced ejection fraction are largely either repurposed anti-hypertensives that blunt overactivation of the neurohormonal system or diuretics that decrease congestion. However, they do not address the symptoms of heart failure that result from reductions in cardiac output and reserve. Over the last few decades, numerous attempts have been made to develop and test positive cardiac inotropes that improve cardiac haemodynamics. However, definitive clinical trials have failed to show a survival benefit. As a result, no positive inotrope is currently approved for long-term use in heart failure. The focus of this state-of-the-art review is to revisit prior clinical trials and to understand the causes for their findings. Using the learnings from those experiences, we propose a framework for future trials of such agents that maximizes their potential for success. This includes enriching the trials with patients who are most likely to derive benefit, using biomarkers and imaging in trial design and execution, evaluating efficacy based on a wider range of intermediate phenotypes, and collecting detailed data on functional status and quality of life. With a rapidly growing population of patients with advanced heart failure, the epidemiologic insignificance of heart transplantation as a therapeutic intervention, and both the cost and morbidity associated with ventricular assist devices, there is an enormous potential for positive inotropic therapies to impact the outcomes that matter most to patients. [ABSTRACT FROM AUTHOR]

Objectives To assess the clinical effectiveness of beta-blocker therapy in individuals with heart failure ( HF) and chronic lung disease and of angiotensin-converting enzyme inhibitors ( ACE-Is) and angiotensin II receptor blockers ( ARBs) in individuals with HF and chronic kidney disease. Design Retrospective cohort study. Setting Community. Participants Individuals with HF with reduced ejection fraction ( HFr EF) or HF with preserved ejection fraction ( HFp EF). Methods We undertook separate new-user cohort studies to assess the effectiveness of beta-blocker therapy in treating HF and chronic lung disease and ACE-Is and ARBs in treating HF and chronic kidney disease ( CKD). Individuals with a chronic lung disease diagnosis were included in the group with HF and chronic lung disease ( International Classification of Diseases, Ninth Revision, codes 490-496, 518). Individuals with an estimated glomerular filtration rate less than 60 mL/min per 1.73 m2 were included in the group with HF and CKD. The clinical outcomes of interest were death from any cause, hospitalization for HF, and hospitalization for any reason. We fitted pooled logistic marginal structural models using inverse probability weighting, stratified according to HF type. Results For individuals with HFr EF with chronic lung disease, beta-blocker therapy was protective against death (relative risk ( RR) = 0.58, 95% confidence interval ( CI) = 0.44-0.77) and hospitalization for HF ( RR = 0.78, 95% CI = 0.60-1.00). For those with HFp EF, no statistically significant associations between beta-blocker therapy use and any of the outcomes were observed. We found ACE-I and ARB use to be protective against all three outcomes of interest in individuals with HFr EF (death from any cause: RR = 0.60, 95% 0.40-0.91; hospitalization for HF: RR = 0.43, 95% CI = 0.28-0.67; hospitalization for any reason: RR = 0.63, 95% CI = 0.45-0.89, respectively) and those with HFp EF (death from any cause: RR = 0.52, 95% CI = 0.33-0.81; hospitalization for HF: RR = 0.35, 95% CI = 0.18-0.68; hospitalization for any reason: RR = 0.67, 95% CI = 0.47-0.95). Conclusion Large observational studies may allow for identification of important subgroups of individuals with HF that might benefit from existing treatment approaches. Our findings may also better inform the design of more-definitive future observational studies and randomized trials. [ABSTRACT FROM AUTHOR]

Objective: The accepted definition of silent sinus syndrome (SSS) excludes posttraumatic cases. To challenge current exclusion criteria of antecedent facial trauma, we have identified all published cases of posttraumatic SSS in English literature, including a new representative case from our institution.Data Sources: MEDLINE, EMBASE, and Scopus databases.Review Methods: All case reports and case series published in English literature from 1964 through August 2016 were sequentially identified. Authors of cases with missing information were contacted for completion.Results: Thirteen documented cases of posttraumatic SSS were identified through the literature review. An additional case from our institution was presented, bringing the total reported case count to 14. Time from initial trauma to presentation ranged from 2 months to 32 years, with a median duration of 6 months. Endoscopic sinus surgery (ESS) with either concurrent or staged orbital floor implant repair was used to treat posttraumatic SSS in 64% of reported cases. Three patients had ESS alone, with one case showing postoperative improvement in enophthalmos.Conclusion: Recent emergence of case reports of SSS postorbital and facial trauma challenge the current exclusion criteria of precedent facial trauma. Posttraumatic SSS is rare, but the availability of cross-sectional imaging pre- and postdevelopment of SSS makes a strong case for a causal relationship. Laryngoscope, 127:1520-1524, 2017. [ABSTRACT FROM AUTHOR]

Objectives To examine whether the total burden of comorbidity and pattern of co-occurring conditions varies in individuals with heart failure ( HF) with preserved left ventricular ejection fraction ( LVEF) ( HF-P) or HF with reduced LVEF ( HF-R). Design Cross-sectional cohort study. Setting Four participating health plans within the National Heart, Lung, and Blood Institute-sponsored Cardiovascular Research Network. Participants All members aged 65 and older with HF based on hospital discharge and ambulatory visit diagnoses. Measurements Participants with a LVEF of 50% or greater were classified as having HF-P. Presence of cardiac and noncardiac comorbidities was obtained from health plan administrative databases. Results Of 23,435 individuals identified with HF and LVEF information, 53% (12,407) had confirmed HF-P (mean age 79.6; 60% female). More than three-quarters of the sample had three or more co-occurring conditions in addition to HF, and half had five or more cooccurring conditions. Participants with HF-P had a slightly higher burden of comorbidity than those with HF-R (mean 4.5 vs 4.4, P = .002). Patterns of how specific conditions co-occurred did not vary in participants with preserved or reduced systolic function. Conclusion There is a high degree of comorbidity and multiple morbidity in individuals with HF. The burden and pattern of comorbidity varies only slightly in individuals with preserved or reduced LVEF. [ABSTRACT FROM AUTHOR]

Heart failure (HF) is a major cause of mortality and morbidity, representing a leading cause of death and hospitalization among U.S. Medicare beneficiaries. Advances in science have generated effective interventions to reduce adverse outcomes in HF, particularly in patients with reduced left ventricular ejection fraction. Unfortunately, effective therapies for heart failure are often not utilized in an effective, safe, timely, equitable, patient-centered, and efficient manner. Further, the risk of adverse outcomes for HF remains high. The last decades have witnessed the growth of efforts to measure and improve the care and outcomes of patients with HF. This paper will review the evolution of quality measurement for HF, including a brief history of quality measurement in medicine; the measures that have been employed to characterize quality in heart failure; how the measures are obtained; how measures are employed; and present and future challenges surrounding quality measurement in heart failure. [ABSTRACT FROM AUTHOR]

Aims: Hospitalized heart failure (HF) patients are at high risk for death and readmission. We examined the incremental value of data obtained 1 week after HF hospital discharge in predicting mortality and readmission. [ABSTRACT FROM PUBLISHER]

Aims: The prevalence and importance of liver function test (LFT) abnormalities in a large contemporary cohort of heart failure patients have not been systematically evaluated. [ABSTRACT FROM PUBLISHER]

To examine the uniqueness and relationship of islands in the San Diegan Province using reef fishes.Pacific coast of Baja and Southern California.Quantitative scuba surveys and statistics were used. Between June 2000 and August 2002, the nearshore rocky-reef fishes of eight southern California and Baja California islands were quantitatively surveyed. The islands surveyed were: Santa Cruz, San Nicolas, Santa Barbara, Santa Catalina, San Clemente, North Coronado, San Martin and San Benito. These islands span the latitudinal range of offshore islands within the San Diegan marine province. This regional scale approach provided not only the first quantitative description of rocky-reef fishes at five of these islands, but also allowed comparisons with known biogeographical patterns.Here we discuss the distribution and abundance of 84 conspicuous rocky-reef fishes from 35 families. In general, the richness, diversity and composition of fish assemblages at these islands were found to reflect previously described biogeographical processes. The rocky reef fish assemblages of all islands in the survey were found to be significantly distinctive form each other. Phenetic analyses revealed two clusters. San Clemente, Santa Catalina and North Coronado clustered as a warm-water assemblage in the middle of the San Diegan Province. The remaining islands grouped together as a cold-water assemblage, despite the geographically disjunct position of the islands within this cluster. The relatedness of islands was independent of distance. Examination of the most common fish species at all islands revealed that while some conformed to the north–south trending density distributions predicted by previous investigators, the distribution of others could not be explained by latitude or temperature regimes. No single pattern explained the density of fishes at all islands. Both the rock croaker,Parequessp., and flag cabrilla,Epinephelus labriformis, were observed at San Benito during these surveys, representing northern range extensions and may be indicators of the warming trend observed in this marine province.For nearshore rocky-reef fishes, the islands of the San Diegan marine province are distinct and their interrelatedness is independent of the distance between them. [ABSTRACT FROM AUTHOR]

The sex ratios, growth, and mortality of the golden spotted rock bass Paralabrax auroguttatus (Serranidae) were determined for populations from Islas Encantadas and Bahía de los Angeles in the Gulf of California. Specimens ranged from 137 to 479 mm standard length and from 135 to 3,100 g. Sagittal otoliths were used to determine age. A von Bertalanffy model of growth for both populations combined was estimated as Lt = 474.4·(1 − e−0.115( t + 2.093)), where Lt is fish length at age t. This model is comparable to those for other rock basses. The relationship between length and weight ( W) followed the power function W = 0.00002· L3.0797 ( r2 = 0.96) with no difference between males and females. The mortality rate was estimated as 49% per year for fish of age 5 and older. In our Bahía de los Angeles samples, the sex ratio was significantly skewed, with more males than females. The mean size of females was significantly smaller at Bahía de los Angeles than in Islas Encantadas. Examination of the sex ratios for these two populations suggested that this species is gonochoristic. [ABSTRACT FROM AUTHOR]

Explores the implications of introducing acceleration as a factor in regional economic stabilization theory. Implications of the acceleration principle as a source of instability in regional economies; Theory of regional stabilization; Development of a dynamic model of regional income determination; Implications of a regional stabilization scheme in reducing the amplitude of the regional business cycle.

Determinants of host-drug interaction comprise a complex of potentially variable factors. The complexity of this variability compromises the forecasting of favorable response in individual patients given standard therapy. Substantial success with current forms of chemotherapy may require that biochemical, pharmacologic, and clinical profiles be established for each cancer patient whereby the use of drug and drug combination can be rationally applied. The significance of evaluating clinical pharmacokinetic parameters in patients with cancer is placed in perspective with other factors relevant to individual drug response. [ABSTRACT FROM AUTHOR]

The article offers information about sea animals of submarine canyons. Topics discussed include founding of endangered specie the giant sea bass (Stereolepis gigas); talks about length and exceeding weights of species among reef fishes; and abundance of phytoplankton and zooplankton in nutrient rich water.

Background: Atrial fibrillation (AF) and heart failure with reduced ejection fraction frequently coexist. The AATAC (Ablation versus Amiodarone for Treatment of persistent Atrial fibrillation in patients with Congestive heart failure and an implantable device) trial suggests that catheter ablation may benefit these patients. However, applicability to contemporary ambulatory cardiology practice is unknown., Methods and Results: Using the outpatient National Cardiovascular Data Registry ® Practice Innovation and Clinical Excellence Registry, we identified participants meeting AATAC enrollment criteria between 2013 and 2014. Treatment with medications and procedures was assessed at registry inclusion. From 164 166 patients with AF and heart failure, 8483 (7%) patients potentially met AATAC inclusion criteria. Eligible subjects, compared to AATAC trial participants, were older (mean age, 71.2±11.4 years) and had greater comorbidity (coronary artery disease 79.2%, hypertension 82.4%, and diabetes mellitus 31.8%). AF was predominantly paroxysmal (65.5%), rather than persistent/permanent (16.7%) or new onset (17.8%), whereas all patients in the AATAC trial had persistent AF. Commonly used atrioventricular-nodal blocking agents were carvedilol (71.2%), digoxin (31.9%), and metoprolol (27.1%). Rhythm control with anti-arrhythmic drugs was reported in 29.0% of AATAC eligible patients (predominantly amiodarone [24.6%]) and 9.3% had undergone catheter ablation. Patients who underwent ablation were more likely to be younger and have less comorbidities than those who did not., Conclusions: Among the contemporary ambulatory AF/heart failure with reduced ejection fraction population, treatment is predominantly rate control with few catheter ablations. Application of AATAC findings has the potential to markedly increase the use of catheter ablation in this population, although significant differences in clinical profiles might influence ablation outcomes in practice., (© 2017 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley.)