The association between neutrophil gelatinase-associated lipocalin and clinical outcome in chronic heart failure: results from CORONA*

OBJECTIVE

To study the prognostic value of neutrophil gelatinase-associated lipocalin (NGAL) in chronic heart failure (HF) of ischaemic aetiology.

BACKGROUND

Neutrophil gelatinase-associated lipocalin is a marker of kidney injury as well as matrix degradation and inflammation and has previously been shown to be increased in HF. We investigated whether serum NGAL levels could provide prognostic information in chronic HF.

METHODS

We assessed NGAL as a predictor of primary outcomes (cardiovascular death, nonfatal stroke and nonfatal myocardial infarction, n = 307) and all-cause mortality (n = 321), cardiovascular mortality (n = 259) and hospitalization (n = 647) as well as the number of hospitalizations during follow-up for all (n = 1934) and CV causes (n = 1204) in 1415 patients with chronic HF (≥60 years, New York Heart Association class II-IV, ischaemic systolic HF) in the CORONA population, randomly assigned to 10 mg rosuvastatin or placebo. Results.  Multivariate analysis revealed that NGAL added significant information when adjusting for clinical variables, but was no longer significant when further adjusting for apolipoprotein A-1 (ApoA-1), glomerular filtration rate (GFR), C-reactive protein (CRP) and N-terminal pro-brain natriuretic peptide (NT-proBNP). However, belonging to the highest NGAL tertile was associated with more frequent hospitalization, even after adjusting for clinical variables, GFR and ApoA-1, but not after adjusting for CRP and NT-proBNP. There was no interaction between rosuvastatin treatment and NGAL. Conclusion.  Neutrophil gelatinase-associated lipocalin added no significant information to NT-proBNP and GFR in a multivariate model for primary and secondary end-points.

Economic evaluation of the impact of nicorandil in angina (IONA) trial

OBJECTIVE

To estimate the net cost of adding nicorandil to usual treatment for patients with angina and to compare this with indicators of health benefit.

DESIGN

Cost effectiveness analysis.

SETTING

Based on results of the IONA (impact of nicorandil on angina) trial.

PATIENTS

Patients with angina fulfilling the entry criteria for the IONA trial.

INTERVENTIONS

In one arm of the trial nicorandil was added to existing antianginal treatment and compared with existing treatment alone.

MAIN OUTCOME MEASURES

Costs were for use of hospital resources (for cardiovascular, cerebrovascular, and gastrointestinal reasons), nicorandil, and care after hospital discharge. Benefits were assessed in three ways: (1) IONA trial primary outcome (coronary heart disease (CHD) death, non-fatal myocardial infarction, or hospital admission for cardiac chest pain); (2) acute coronary syndrome (CHD death, non-fatal myocardial infarction, or unstable angina); and (3) event-free survivors at the end of the trial.

RESULTS

The net cost for each additional IONA trial end point averted was -5 pounds sterling (-7 euros). The net cost for each case of acute coronary syndrome averted was -8 pounds sterling (-12 euros). The net cost for each event-free survivor was -5 pounds sterling (-7 euros). These figures are based on gastrointestinal events that were judged definitely or probably related to nicorandil. When all gastrointestinal events were included these three ratios rose to 567 pounds sterling (835 euros), 886 pounds sterling (1305 euros), and 516 pounds sterling (760 euros), respectively.

CONCLUSIONS

A substantial amount of the additional cost of nicorandil is offset by reduced use of hospital services. The limited comparisons possible with other CHD interventions suggest that nicorandil compares favourably.

Patients strategies for managing medication for chronic heart failure

OBJECTIVES

To explore patients views of the management of medication of chronic heart failure (CHF); to explore in what circumstances they have difficulties in managing medication.

DESIGN

Qualitative analysis of in-depth interviews using a constant comparative approach.

PARTICIPANTS

Patients attending an outpatients clinic with a primary diagnosis of CHF due to left ventricular systolic dysfunction, NYHA Class II or III symptoms, and a history of hospital admission for heart failure.

RESULTS

50 patients were recruited, average age 67.1 years with ranges between 41 and 80 years. 26 were classified as NYHA Class II and 24 Class III. Patients reported developing routines and back up strategies to help with the complex task of medication-taking. They also described circumstances in which they were more likely not to take medication.

CONCLUSIONS

This study demonstrates, with a large sample of respondents, the complexities of medication-taking and the difficulties of maintaining constant medication over a long period of time. The study provides examples of patients' strategies for so doing. Health care professionals should recognise that concordance may vary but explore ways in which they can help patients establish routines.

Heart failure with preserved left ventricular systolic function: a hospital cohort study

OBJECTIVE

To investigate how patients with heart failure with preserved left ventricular systolic function (LVSF) compare with patients with reduced LVSF.

DESIGN

Cohort study.

SETTING

Urban university hospital.

PATIENTS

528 index emergency admissions with heart failure during the year 2000. Information on LVSF and follow up was available for 445 (84%) of these patients.

RESULTS

130 (29%) patients had preserved LVSF (defined as an ejection fraction > 40%). The median follow up was 814 days (range 632-978 days). The average (SD) age was 72 (13) years. Women accounted for 62% and 45% of patients with preserved and reduced LVSF, respectively (p = 0.001). Patients with preserved LVSF (compared with those with reduced LVSF) had a higher prevalence of left ventricular hypertrophy (56% v 29%) and aortic valve disease (mean gradient > 20 mm Hg; 31% v 9%). Fewer patients with preserved LVSF received an angiotensin converting enzyme inhibitor (65% v 78%, p = 0.008) or spironolactone (12% v 21%, p = 0.027). Anaemia tended to occur more often in patients with preserved LVSF than in those with reduced LVSF (43% v 33% for women, p = 0.12; 59% v 49% for men, p = 0.22). There was a similarly high prevalence of significant renal dysfunction in both groups (estimated glomerular filtration rate < 60 ml/min/1.73 m2 in 68% with preserved and 64% with reduced LVSF, p = 0.40). Mortality was similar in both groups (preserved versus reduced 51 (39%) v 132 (42%), p = 0.51). Compared with patients with reduced LVSF, patients with preserved LVSF tended to have a lower risk of death or hospital admission for heart failure (56 (42%) v 165 (53%), p = 0.072) but a similar rate of death or readmission for any reason.

CONCLUSION

Patients with preserved LVSF had more co-morbid problems than those with reduced LVSF; however, prognosis was similar for both groups.

Heart failure and statins—Why do we need a clinical trial?

The effect of statins to reduce mortality and morbidity in primary and secondary prevention as well as in acute coronary syndrome is well established. Recent data show that pleiotropic effects might also have direct effects on the myocardial cell. However, in chronic heart failure the outcome is inversely related to LDL-plasma concentrations and other pleiotropic effects might impair mitochondrial function. Since there are no safety data on the use of statins in chronic heart failure, a controlled randomized and placebo-controlled trial is urgently needed.

How much responsibility should heart failure nurses take?

This article examines the emerging role of the heart failure nurse and the responsibilities and educational and training requirements surrounding such a role. There may be variations in the role and its responsibilities in different health care settings. However the principles are similar and include: history taking, carrying out clinical assessment and making appropriate decisions about patient management within the context of practice. An example of this is nurse supervision of adjusting and titration of medication in a clinic setting or in the patient's own home. A major challenge to this role is defining the limitations and scope of practice. Patients with chronic heart failure (CHF) are generally a frail, elderly population, and often have significant other co-morbidities. They can be on multiple medications and are frequently prescribed sub-optimal doses of evidence-based medication. Many patients are not managed by specialists, thus creating a huge potential for improved management.

N-terminal pro B type natriuretic peptide, but not the new putative cardiac hormone relaxin, predicts prognosis in patients with chronic heart failure

OBJECTIVE

To determine whether the plasma concentration of the putative new cardiac hormone relaxin is predictive of clinical outcome in patients with chronic heart failure (CHF).

DESIGN

Plasma relaxin and N-terminal pro B type natriuretic peptide (NT pro BNP) concentrations were measured in 87 patients admitted in an emergency with CHF caused by left ventricular systolic dysfunction. These were related to death and death or readmission with CHF over the following year.

SETTING

Western Infirmary, Glasgow, UK.

MAIN OUTCOME MEASURES

Plasma concentrations of relaxin and NT pro BNP; time to death or hospitalisation caused by heart failure.

RESULTS

Plasma concentrations of both relaxin and NT pro BNP were greatly increased. Of the 43 patients with NT pro BNP above the group median concentration, 23 (53%) died and 30 (70%) died or were hospitalised with CHF. Among the 44 with concentrations below the median, these numbers were 5 (11%) and 12 (27%), respectively (p < 0.0001 and p < 0.0001, respectively). Plasma NT pro BNP concentration remained an independent predictor of an adverse clinical outcome in a multivariate analysis. Of the 42 patients with a relaxin concentration above the median, 13 (31%) died and 20 (48%) died or were hospitalised. Below the median, these numbers were 15 of 45 (33%) and 22 of 45 (49%) (p = 0.76 and p = 0.84, respectively).

CONCLUSIONS

NT pro BNP is a powerful and independent predictor of outcome in CHF, whereas relaxin, also secreted by the heart in increased amounts in CHF, is not.