Heartsong

Introduction: The comparative effectiveness of differing doses of guideline-directed medical therapy (GDMT) for heart failure with reduced ejection fraction (HFrEF) on clinical and patient-reported outcomes in US clinical practice is unknown. Methods: This analysis included 4,832 US outpatients with chronic HFrEF in the CHAMP-HF registry with available medication data and no contraindications at baseline. Baseline dosing of ACE inhibitor (ACEI)/ angiotensin II receptor blocker (ARB)/ angiotensin receptor-neprilysin inhibitor (ARNI), beta-blocker, and mineralocorticoid receptor antagonist (MRA) therapies were examined. Multivariable models assessed associations between medication dosing and clinical outcomes over 24 months (all-cause mortality, HF hospitalization) and patient-reported outcomes at 12 months (change in Kansas City Cardiomyopathy Questionnaire Overall Summary Score [KCCQ-OS]). Results: After adjustment, compared with target dosing, lower dosing was independently associated with higher all-cause mortality for ACEI/ARB/ARNI (overall p<0.001) and beta-blocker therapies (overall p=0.042) (Table) . Lower dosing of ACEI/ARB/ARNI was independently associated with higher risk of HF hospitalization (overall p=0.046), but beta-blocker dosing was not. Target dosing of MRA was not associated with risk of mortality or HF hospitalization. For each GDMT, compared with target dosing, lower dosing was not associated with change in KCCQ-OS at 12 months, with potential exception of worsening KCCQ-OS with lower dosing of ACEI/ARB/ARNI. Conclusions: In this contemporary US outpatient HFrEF registry, target dosing of ACEI/ARB/ARNI and beta-blocker was associated with reduced mortality, and variably associated with other outcomes. MRA dosing was not associated with outcomes. Unmeasured differences between patients receiving differing dosages may explain differences between results seen here compared with randomized trials.

To examine relationships amongst parental post-traumatic stress symptoms, parental post-traumatic growth, overprotective parenting, and child emotional/behavioural problems in families of children with critical CHD. Sixty parents (15 fathers) of children aged 1-6 completed online questionnaires assessing parental post-traumatic stress symptoms and post-traumatic growth, overprotective parenting, and child emotional/behavioural problems. Bivariate correlations and mediational analyses were conducted to evaluate overprotective parenting as a mediator of the association between parental post-traumatic stress symptoms and child emotional/behavioural problems. Parents reported significant post-traumatic stress symptoms, with over 18% meeting criteria for post-traumatic stress disorder and 70% meeting criteria in one or more clusters. Parental post-traumatic growth was positively correlated with intrusion (r = .32, p = .01) but it was not associated with other post-traumatic stress symptom clusters. Parental post-traumatic stress symptoms were positively associated with overprotective parenting (r = .37, p = .008) and total child emotional/behavioural problems (r = .29, p = .037). Overprotective parenting was positively associated with total child emotional/behavioural problems (r = .45, p = .001) and fully mediated the relationship between parental post-traumatic stress symptoms and child emotional/behavioural problems. Overprotective parenting mediates the relationship between parental post-traumatic stress symptoms and child emotional and behavioural problems in families of children with CHD. Both parental post-traumatic stress symptoms and overprotective parenting may be modifiable risk factors for poor child outcomes. This study highlights the need for interventions to prevent or reduce parental post-traumatic stress symptoms and to promote effective parenting following a diagnosis of CHD.

The stimulus to create this document was the recognition that ionizing radiation-guided cardiovascular procedures are being performed with increasing frequency, leading to greater patient radiation exposure and, potentially, to greater exposure for clinical personnel. Although the clinical benefit of these procedures is substantial, there is concern about the implications of medical radiation exposure. The American College of Cardiology leadership concluded that it is important to provide practitioners with an educational resource that assembles and interprets the current radiation knowledge base relevant to cardiovascular procedures. By applying this knowledge base, cardiovascular practitioners will be able to select procedures optimally, and minimize radiation exposure to patients and to clinical personnel. Optimal Use of Ionizing Radiation in Cardiovascular Imaging: Best Practices for Safety and Effectiveness is a comprehensive overview of ionizing radiation use in cardiovascular procedures and is published online. To provide the most value to our members, we divided the print version of this document into 2 focused parts. Part I: Radiation Physics and Radiation Biology addresses the issue of medical radiation exposure, the basics of radiation physics and dosimetry, and the basics of radiation biology and radiation-induced adverse effects. Part II: Radiological Equipment Operation, Dose-Sparing Methodologies, Patient and Medical Personnel Protection covers the basics of operation and radiation delivery for the 3 cardiovascular imaging modalities (x-ray fluoroscopy, x-ray computed tomography, and nuclear scintigraphy) and will be published in the next issue of the Journal.

Background: Heart failure with reduced ejection fraction (HFrEF) has a significant impact on patients’ health status. A primary goal of treatment is to minimize patients’ symptoms, while maximizing their functional status and quality of life. The variability across outpatient practices, and the characteristics of those practices, in optimizing patients’ health status is unknown. Methods: In the multicenter CHAMP-HF registry, the association between practice characteristics and Kansas City Cardiomyopathy Questionnaire Overall Summary Scores (KCCQ-os) in 3,494 patients across 140 US centers was assessed with hierarchical logistic regression adjusting for 23 patient characteristics to predict excellent health status (KCCQ-os ≥75). A median odds ratio (MOR) was estimated to quantify the average relative difference a patient would exhibit excellent health status when being treated at one random practice versus another. Results: The mean (±standard deviation) KCCQ-os was 64.2±24, and 39% (n=1,380) had a KCCQ-os ≥75. In a fully-adjusted model, patients were more likely to have excellent health status if the practice was in a suburban (vs. urban) location (OR=1.47, p = 0.02), while those enrolled at a primary care (vs. cardiology) setting were less likely to have a KCCQ≥75 (OR=0.52, p = 0.02). The MOR across practices was 1.69 (95% CI=1.46, 1.90; p < 0.0001) indicating a median 69% higher odds of a statistically identical patient having excellent health status when treated at one random practice versus another. Conclusion: In this first large, contemporary assessment of health status in outpatients with HFrEF, we found marked variation by site in patients having excellent health status. Proposed efforts to use patient-reported outcomes as a quality measure may support improved attention to patients’ health status in clinical care.

American College of Cardiology (ACC)/American Heart Association (AHA) performance measure sets can serve as vehicles to accelerate appropriate translation of scientific evidence into clinical practice. These documents are intended to provide practitioners and institutions that deliver cardiovascular