Clinical Investigator, Brigham and Women's Hospital
I am developing novel systems of care to alleviate the burden of heart failure.
Heart failure is a debilitating syndrome that reduce life expectancy and patient quality of life. Millions of Americans have chronic heart failure, which can be the result of any damage or injury to the heart, such as a heart attack. Medication therapy can slow the progression of heart failure, but the 5-year mortality rate for heart failure is 50%. Although outward manifestations of heart failure appear benign, outcomes for patients with heart failure are similar to or worse than many common cancers. Heart failure is truly an unrecognized cause of suffering and death worldwide.
The natural history of heart failure is characterized periods of clinical stability interrupted by periods of decompensation. During a decompensation, the most common symptoms are severe shortness of breath and swelling in the legs and trunk. For a patient with heart failure, dressing oneself in the morning is the metabolic and energetic equivalent of running a marathon for a person without heart failure. Heart failure decompensation are indicative of disease progression and significant resources are required to regain patient stability. However, no treatments have been shown to slow or reverse disease progression in patients with decompensated heart failure.
My research is focusing on understanding the mechanisms of decompensation and developing novel medication and non-medication strategies to improve the patient's prognosis. This research will encompass a range of studies, including in vivo and ex vivo physiology, biomarkers, pharmacologic treatments and systems of care. The ultimate goal of my research program is to improve the care and outcomes of patients with this debilitating condition.
Abstract: This study sought to evaluate the effectiveness of intravenous (IV) diuretic treatment for volume management in heart failure (HF).Limited data exist regarding IV diuretics for the outpatient treatment of volume overload in HF patients.We analyzed 60 consecutive patients with chronic HF and clinical evidence of worsening congestion who received a bolus and 3-h IV infusion of furosemide at an outpatient HF clinic. Diuretic dosing was derived from the maintenance oral loop diuretic dose with a standardized conversion algorithm. Outcomes included urine output during the visit, weight loss at 24 h, and hospitalization and mortality at 30 days. Safety outcomes included hypokalemia and worsening of renal function. Outcomes were analyzed across subgroups defined by maintenance diuretic dose and ejection fraction (EF).The median age of the cohort was 70 years (interquartile range [IQR]: 58 to 80 years), and the median daily loop diuretic dose was 240 mg (IQR: 80 to 800 mg) oral furosemide or equivalent. Twenty-six patients (43.3%) were women, and 36 (60%) had an EF ≤45%. For the entire cohort, the median urine output and 24-h weight loss were 1.1 l (IQR: 0.6 to 1.4 l) and 1.1 kg (IQR: 0.2 to 1.9 kg), respectively. Outcomes were similar across patients with varying maintenance diuretic doses (<40 mg, 40 to 160 mg, 160 to 300 mg, or >300 mg of furosemide or equivalent) and in patients with reduced or preserved EF. Transient worsening of renal function and hypokalemia occurred in 10 patients (8.9%) and 4 patients (3.5%). Although hospitalization was reported as imminent for 28 patients (52.8%), the observed rate of all-cause hospitalization was 31.7% at 30 days with no deaths.Short courses of IV diuretics for volume management in patients with HF were safe and associated with significant urine output and weight loss across a wide range of maintenance diuretic doses and EF. This strategy may provide an alternative to hospitalization for the management of selected HF patients.
Pub.: 15 Dec '15, Pinned: 14 Aug '17
Abstract: Innovative treatment strategies for decompensated heart failure (HF) are required to achieve cost savings and improvements in outcomes. We developed a decision analytic model from a hospital perspective to compare two strategies for the treatment of decompensated HF, ambulatory diuretic infusion therapy and hospitalization (standard care), with respect to total heart failure hospitalizations and costs. The ambulatory diuretic therapy strategy included outpatient treatment with high doses of IV loop diuretics in a specialized HF unit while standard care included hospitalization for IV loop diuretic therapy. Model probabilities were derived from the outcomes of patients who were treated for decompensated HF at Brigham and Women’s Hospital (Boston, MA). Costs were based on Centers for Medicare and Medicaid reimbursement and the available literature. Based on a sample of patients treated at our institution, the ambulatory diuretic therapy strategy was estimated to achieve a significant reduction in total heart failure hospitalizations compared with standard care (relative reduction 58.3%). Under the base case assumptions, the total cost of the ambulatory diuretic therapy strategy was $6,078 per decompensation episode per 90 days compared to $12,175 per 90 days with standard care, for a savings of $6,097. The cost savings associated with the ambulatory diuretic strategy were robust against variation up to 50% in costs of ambulatory diuretic therapy and the likelihood of post-treatment hospitalization. An exploratory analysis suggests that ambulatory diuretic therapy is likely to remain cost-saving over the long-term. In conclusion, this decision analytic model demonstrates that ambulatory diuretic therapy is likely to be cost-saving compared to hospitalization for the treatment of decompensated HF from a hospital perspective. These results suggest that implementation of outpatient HF units that provide ambulatory diuretic therapy to well-selected subgroup of patients may result in significant reductions in healthcare costs while improving the care of patients across a variety of healthcare settings.
Pub.: 13 Aug '16, Pinned: 14 Aug '17