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INTRODUCTION: Heart failure is a clinical condition that notably affects the lives of patients in rural areas. Partnering of a rural satellite hospital with an urban academic medical center may provide geographically underrepresented populations with heart failure an opportunity to access to controlled clinical trials (CCTs). METHODS: We report our experience in screening, consenting and enrolling subjects at the VCU Health Community Memorial Hospital (VCU-CMH) in rural South Hill, Virginia, that is part of the larger VCU Health network, with the lead institution being VCU Health Medical College of Virginia Hospitals (VCU-MCV), Richmond, VA. Subjects were enrolled in a clinical trial sponsored by the National Institutes of Health and assigned to treatment with an anti-inflammatory drug for heart failure or placebo. We used the electronic health record and remote guidance and oversight from the VCU-MCV resources using a close-loop communication network to work with local resources at the facility to perform screening, consenting and enrollment. RESULTS: One hundred subjects with recently decompensated heart failure were screened between January 2019 and August 2021, of these 61 are enrolled to date: 52 (85%) at VCU-MCV and 9 (15%) at VCU-CMH. Of the subjects enrolled at VCU-CMH, 33% were female, 77% Black, with a mean age of 52 ± 10 years. CONCLUSION: The use of a combination of virtual/remote monitoring and guidance of local resources in this trial provides an opportunity for decentralization and access of CCTs for potential novel treatment of heart failure to underrepresented individuals from rural areas.

Study objective: Dobutamine stress echocardiography (DSE) has been used as a screening tool for coronary artery disease after heart transplantation and in the identification of patients at risk for development of cardiac events. However, the safety profile of high-dose dobutamine in heart transplant patients has not been systematically examined. Accordingly, we studied the safety profile and hemodynamic responses to escalating doses of dobutamine to determine the influence of denervation. Design: We assessed the hemodynamic responses, heart rate (HR), and arterial BP indexes (mean arterial pressure, systolic BP [SBP], diastolic BP [DBP], and pulse pressure) to dobutamine in 87 heart transplant patients ([mean 6 SD] age, 51 6 1 years) and compared the results with 97 nontransplant patients (age, 63.0 6 1 years) who served as innervated control subjects. Measurements and results: The baseline HR (84 6 2v s 696 1 beats/minute, respectively; p < 0.001) and peak HR response (144 6 2v s 1176 2 beats/minute, respectively; p < 0.001) were significantly higher in heart transplant patients than in the nontransplant patients. SBP was lower in heart transplant patients than in nontransplant patients at baseline (131 6 2v s 1386 2 mm Hg, respectively; p < 0.02) and at peak (150 6 3v s 1586 3 mm Hg, respectively; p < 0.03). However, baseline DBP was higher in transplant patients than in nontransplant patients (86 6 1 vs 77 6 1 mm Hg, respectively; p < 0.001). The decrease in DBP was similar in both groups (15 mm Hg). The dose-response curve for HR was shifted leftward in heart transplant patients. Heart transplant patients attained a higher absolute HR at each infusion stage and higher rates of increase, but the decrease in DBP was not significantly different in the two groups. Conclusions: These results show that there is augmented chronotropic response and expected decline in DBP in response to dobutamine infusion in heart transplant patients. This increase in myocardial oxygen demand and a decrease in coronary perfusion pressure may be important mechanisms in the development of ischemic abnormalities that are detectable as regional dysynergy on echocardiography. (CHEST 1999; 116:1587‐1592)

Dobutamine Stress Echocardiography(DSE) is widely used as a non-invasive test to screen for the presence of coronary artery disease ICAD). Its ability to accurately separate patients (pts) with limited vessel (0 or 1 vessel) disease (LVD) from high risk multi-vessel 12 or 3) disease (MVD) pts, in the presence of decreased resting left ventricular ejection fraction (LVEF) is unknown. Accordingly, we analyzed the results from 136 consecutive pts who underwent both coronary angiography and DSE. DSE was performed with graded dobutamine infusion of 5,10,20,30, and 40 μg/kg/min in 5 min stages, and WMA was graded using a 16 myocardial segment model. DSE was considered indicative of MVD when there were at least two abnormal contiguous segments in two different coronary distributions. CAD was considered significant when g 50% luminal area narrowing was present. There were 27 pts with O-V, 52 with 1-V, 40 with 2-V, and 17 with 3V CAD. The data from 59 of 136 (42%) pts who had an LVEF ≤ 40% were compared to the 79 pts with an LVEF g40%: Parameters EF g 40% (N = 79) EF l 40% (N = 57) 0–1 V 2–3 V 0–1 V 2–3 V Sensitivity % 70 67 14 86 Specificity % 67 70 86 26 In pts with LVEF g 40% DSE had similar accuracy in identifying LVD and MVD. In contrast. the specificity of DSE in separating LVD from MVD was poor in patients with decreased LVEF. These results suggest that 11) DSE in an adequate screening test for MVD and (2) baseline LVEF contributes importantly to the overall interpretation of DSE in predicting MVD.