Clinical definition and epidemiology of advanced heart failure

Imaging techniques in cardiac resynchronization therapy

Cardiac resynchronization therapy is a high cost therapeutic option with proven efficacy on improving symptoms of ventricular failure and for reducing both hospitalization and mortality. However, a significant number of patients do not respond to cardiac resynchronization therapy that is due to various reasons. Identification of the optimal pacing site is crucial to obtain the best therapeutic result that necessitates careful patient selection. Currently, using echocardiography for mechanical dyssynchrony assessment performs patient selection. Multi-Detector-Row Computed Tomography (MDCT) and Magnetic Resonance Imaging (MRI) are new imaging techniques that may assist the cardiologist in patient selection. These new imaging techniques have the potential to improve the success rate of cardiac resynchronization therapy, due to pre-interventional evaluation of the venous coronary anatomy, to evaluation of the presence of scar tissue, and to improved evaluation of mechanical dyssynchrony. In conclusion, clinical issues associated with heart failure in potential candidates for cardiac resynchronization therapy, and the information regarding this therapy that can be provided by the imaging techniques echocardiography, MDCT, and MRI, are reviewed.

Palliative care and hospice in advanced heart failure

This paper provides an evidence-based review of the principles underlying palliative care for heart failure (HF), including its pathogenesis, staging, assessment, prognosis, and treatment. Approaches to advanced care planning, symptom management, hospice eligibility, home inotropic infusions, device management and improving the continuum of care in HF are discussed. The reader will be able to recognize advanced HF, use important elements of physical assessment, utilize Web-based prognostic and risk-stratification models, facilitate advance care planning, ensure optimal treatment, manage common symptoms and comorbid conditions, determine hospice eligibility, and consider issues related to withholding or withdrawal of inotropic infusions and devices used in HF refractory to standard treatment. The ultimate goal of palliative care for heart failure is to integrate knowledge of treatment advances and comfort measures and to provide them concurrently in a seamless continuum to patients with late-stage disease.

Managing beyond an uncertain illness trajectory: palliative care in advanced heart failure

A lack of comprehensive and effective palliative care is clearly evident in a number of studies describing the end of life for patients with advanced heart failure. These patients have been portrayed as experiencing a wide array of poorly managed symptoms. The primary rationale for the lack of care has been the uncertain illness trajectory that characterizes living with advanced heart failure. Nurses must manage care beyond the illness trajectory from an emphasis of palliative care as each of these patients may face significant illness burden and even sudden death. The purpose of this paper is to: discuss the current status of palliative care for patients with advanced heart failure; explain the basic pathophysiology and resulting signs and symptoms of advanced heart failure; describe pharmacological and non-pharmacological symptom management strategies for patients with advanced heart failure.

Historical trends in survival of hospitalized heart failure patients: 2000 versus 1995

BACKGROUND

Population-based secular trends in survival of patients with congestive heart failure (CHF) are central to public health research on the burden of the syndrome.

METHODS

Patients 35-79 years old with a CHF discharge code in 1995 or 2000 were identified in 22 Minneapolis-St. Paul hospitals. A sample of the records was abstracted (50% of 1995 records; 38% of 2000 records). A total of 2,257 patients in 1995 and 1,825 patients in 2000 were determined to have had a CHF-related hospitalization. Each patient was followed for one year to ascertain vital status.

RESULTS

The risk profile of the 2000 patient cohort was somewhat worse than that of the 1995 cohort in both sex groups, but the distributions of age and left ventricular ejection fraction were similar. Within one year of admission in 2000, 28% of male patients and 27% of female patients have died, compared to 36% and 27% of their counterparts in 1995, respectively. In various Cox regression models the average year effect (2000 vs. 1995) was around 0.75 for men and 0.95 to 1.00 for women. The use of angiotensin converting-enzyme inhibitors and beta-blockers was associated with substantially lower hazard of death during the subsequent year.

CONCLUSION

Survival of men who were hospitalized for CHF has improved during the second half of the 1990s. The trend in women was very weak, compatible with little to no change. Documented benefits of angiotensin converting-enzyme inhibitors and beta-blockers were evident in these observational data in both men and women.

Management of acute decompensated heart failure: treatment, controversy, and future directions

Acute decompensated heart failure is a growing public health care problem worldwide. The goals of treatment are immediate hemodynamic and symptomatic improvement followed by persistent follow-up with adherence to chronic heart failure guidelines. Controversies have centered around the best treatment options and avoidance of serious adverse events. This article highlights our current understanding of acute decompensated heart failure, discusses the controversy surrounding currently available new vasoactive treatments, and details future potential therapies.

Prognostic value of a novel classification scheme for heart failure: the Minnesota Heart Failure Criteria

The authors present the Minnesota Heart Failure Criteria (MHFC), derived using latent class analysis from widely available items in the Framingham Criteria. The authors used 1995 and 2000 data on hospitalized Minnesota Heart Survey subjects discharged after myocardial infarction or heart failure (N = 7,379). Selected Framingham Criteria variables (dyspnea, pulmonary rales, cardiomegaly, interstitial or pulmonary edema on chest radiograph, S(3) heart sound, tachycardia) plus left ventricular ejection fraction were used. The discriminatory power of the MHFC was evaluated using age- and sex-adjusted 2-year mortality. A five-class latent class analysis model was collapsed into cases and noncases. Mortality estimates discriminated noncases (18%) from cases (43%) (p < 0.001). The MHFC performed better than previous truncated criteria (Framingham Criteria: 26% noncases, 43% cases; Duke Criteria: 29%, 40%; Killip Score: 31%, 44%; Boston Score: 28%, 45%). In a subset of patients admitted for heart failure (n = 5,128), the MHFC identified all but 2% (116/4,746) of cases found with a nearly full version of the Framingham Criteria. In terms of prognostic value, the MHFC are as precise as or more precise than several previous sets of truncated criteria. They closely approximate a nearly full version of the Framingham Criteria but require many fewer variables and can facilitate epidemiologic case-finding for heart failure.

Same Bridge, New Destinations

Mechanical cardiac support with ventricular assist devices is an established therapy for a variety of clinical scenarios, including postcardiotomy shock, "bridge to transplant," and "destination therapy." At present, device development, clinical trial design, regulatory approval, and reimbursement decisions for the clinical application of mechanical cardiac support devices continue to be considered in the context of these clinical indications. Although understandable from a historical perspective, these arbitrary divisions are inconsistent with the clinical realities of advanced heart failure therapy. By narrowly focusing on transplant eligibility at a static point in the clinical course, current guidelines impede the broader application of ventricular assist device technology to the growing population of patients who may benefit from this therapy.

Palliative care for end-stage heart failure

Heart failure is growing in prevalence. Despite an array of treatments targeting a complicated pathophysiology, heart failure ultimately leads to death, and thus there is a clear need to provide palliative care to persons with end-stage heart failure. Palliative care, or education and support of the patient and family and management of distressing symptoms, should be provided throughout the course of the illness. Clinicians need additional information about how to palliate symptoms in advanced heart failure. This article summarizes recent reports about prognostication and identification of patients who are likely to die soon, and the management of fatigue, dyspnea, pain, and depression in heart failure. Palliative care or supportive care of the patient and family should be incorporated into comprehensive care throughout the course of heart failure. Data about hospice care for persons with heart failure are summarized.

A matched-cohort study of health services utilization outcomes for a heart failure disease management program

Chronic disease is the leading cause of illness, disability, and death in the United States, affecting nearly 100 million Americans. Heart failure alone affects nearly 4.9 million Americans, with another 550,000 newly diagnosed cases each year. The aim of this study was to investigate the program effects of a heart failure care support program. A two-group cohort study matching on propensity scores was used to investigate 277 heart failure care support program participants and corresponding matched non-participants. Measures used were rates of hospitalizations, emergency department visits, physician office visits, and heart failure-related prescription drug use and procedures. Relative to the matched control group, program participants experienced 26.3% (p = 0.023) fewer inpatient admissions, 37.9% (p = 0.018) inpatient bed days, 33.3% (p = 0.059) more beta blocker use, 76.7% (p = 0.048) more alpha blocker use, 22.2% (p = 0.006) more lipid panels, 13.4% (p = 0.019) more electrocardiographies, 50.0% (p = 0.008) fewer cardiac catheterizations, and 94.6% (p = 0.014) more pneumonia vaccinations. The current study employs a propensity score matching methodology to select a subset of comparison patients most comparable to treatment patients, and documents the beneficial health services outcomes of participation in a heart failure care support program.

Design of therapy for advanced heart failure

Advanced heart failure has been defined as persistent symptoms (NYHA class III-IV) that limit daily life despite routine therapy with agents of known benefit. Although these symptoms can occur both with low and preserved ejection fraction, the majority of reported experience is with low ejection fraction, usually <25%. For this population with expected one year mortality of 30-50%, over twice the mortality of the landmark trials of medical therapy, there is little trial data to guide management, which is based largely on collected experience. Once the disease has progressed to this stage, therapy focuses upon the twin goals of symptom relief and prolongation of survival and is guided according to the hemodynamic profiles defined by clinical assessment. As symptoms at this stage relate largely to the congestion, therapy is targeted to reduction of elevated pulmonary venous and/or systemic venous pressures to near normal levels. The most common obstacle to relief of congestion is the increasingly recognized cardio-renal syndrome, for which both understanding and therapy are currently limited. Design of the outpatient regimen for advanced heart failure must be tailored to the individual patient. Many patients with advanced heart failure cannot tolerate "target" doses of neurohormonal antagonists, and spironolactone should be used only when clinical and renal function are sufficiently stable and frequently monitored in order to avoid life-threatening hyperkalemia. The clinical benefit of bi-ventricular pacing is substantial for the small proportion of patients likely to benefit. The vast majority of patients will never be eligible for cardiac transplantation or ventricular assist devices. To derive maximal benefit from all available therapies, heart failure disease management with collaboration of physicians and specialized nurses offers the greatest benefit to the greatest number of patients with advanced heart failure.

Psychological interventions for depression in heart failure

BACKGROUND

Heart failure is a common and growing health problem. Depression is prevalent among these patients and is associated with an increased risk of mortality, in some, but not all, studies. Depression may increase the risk of recurrent cardiac events and death, either through direct pathophysiological mechanisms such as thrombogenesis or ventricular arrhythmias, or through behavioural mechanisms. Depressed patients are less likely to adhere to their medication regimen and modify their lifestyle appropriately, thereby increasing the likelihood of recurrent cardiac events and death. The effects of psychological interventions for depression in terms of reducing depression and improving prognosis in patients with heart failure are unknown.

OBJECTIVES

To assess the effects of psychological interventions for depression in people with heart failure on depression and quality of life, morbidity, and mortality in these patients.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials and The Database of Abstracts of Reviews of Effects on The Cochrane Library (Issue 3, 2003), MEDLINE (1951 to August 2003), PsycINFO (1887 to August 2003), CINAHL (1980 to August 2003) and EMBASE (1980 to August 2003). Searches of reference lists of retrieved papers were also made and expert advice was sought. Abstracts from national and international cardiology, psychology, and psychiatry conferences in 2003 and dissertation abstracts were also searched. All relevant foreign language papers were translated.

SELECTION CRITERIA

RCTs of psychological interventions for depression in adults (18 years or older) with heart failure. The primary outcome was a significant reduction in depression. The secondary outcomes were the acceptability of treatment, quality of life, cardiac morbidity (hospital re-admission for heart failure and non-fatal cardiovascular events), reduction of cardiovascular behavioural risk factors, health economics, and death.

DATA COLLECTION AND ANALYSIS

Two reviewers independently screened titles and abstracts of potential studies. Two reviewers independently assessed the full papers for inclusion criteria. Further information was sought from the authors where papers contained insufficient information to make a decision about eligibility.

MAIN RESULTS

No RCTs of psychological interventions for depression in patients with heart failure were identified.

AUTHORS' CONCLUSIONS

Depression is common among patients with heart failure. Randomised controlled trials of psychological interventions for depression in heart failure patients are needed to investigate the impact of such interventions on depression, quality of life, behavioural CVD risk factors, cardiac morbidity, health economics and mortality, given the paucity of such trials in this area and the increasing prevalence of heart failure.

Hospitalized heart failure: rates and long-term mortality

BACKGROUND

Heart failure has been called the "new epidemic of cardiovascular disease," but few studies have described key epidemiologic measures of the syndrome in geographically defined US populations.

METHODS AND RESULTS

We obtained lists of discharge diagnosis codes in 1995 from 22 Minneapolis-St. Paul metropolitan area hospitals; identified patients 35 to 84 years old with a heart failure discharge code; and sampled and abstracted 50% of the hospital records. To identify heart failure-related hospitalizations, we applied 6 published definitions of the syndrome to the sample and selected cases that met at least 4 of the 6 definitions (n = 2887). The patient cohort was followed for 5 to 6 years to ascertain deaths. The rate of hospitalized heart failure ranged from a few dozen hospitalized patients per 100,000 residents ages 35 to 44 years to more than 2000 per 100,000 residents ages 75 to 84, and was consistently higher among men than among women (age-adjusted rate ratio 1.46; 95% CI 1.39-1.54). Within 1-year of the index admission, 37% of male patients and 30% of female patients have died-10 times the annual mortality of the source population. By the end of the follow-up, cumulative mortality reached 72% in men and 66% in women. In multivariable regression of the hazard of death on age, sex, and left ventricular ejection fraction (LVEF), age was a strong determinant of mortality and male patients had modestly higher hazard of death than female patients (adjusted hazard ratio, 1.29; 95% CI 1.18-1.41). LVEF was not a strong predictor of death.

CONCLUSION

A heart failure-related hospitalization is a marker of grave prognosis: only one quarter to one third of the patients survives 5 years after admission. Both the risk of hospitalization for heart failure and the risk of subsequent death are moderately higher in men than in women. LVEF, when measured in the context of heart failure-related hospitalization, is not a strong predictor of death.

A Matched-Cohort Study of Health Services Utilization and Financial Outcomes for a Heart Failure Disease-Management Program in Elderly Patients

OBJECTIVES

To investigate the utilization and financial outcomes of a telephonic nursing disease-management program for elderly patients with heart failure.

DESIGN

A 1-year concurrent matched-cohort study employing propensity score matching.

SETTING

Medicare+Choice recipients residing in Ohio, Kentucky, and Indiana.

PARTICIPANTS

A total of 533 program participants aged 65 and older matched to nonparticipants.

INTERVENTION

Disease-management heart failure program employing a structured, evidence-based, telephonic nursing intervention designed to provide patient education, counseling, and monitoring services.

MEASUREMENTS

Medical service utilization, including hospitalizations, emergency department visits, medical doctor visits, skilled nursing facility (SNF) days, selected clinical indicators, and financial effect.

RESULTS

The intervention group had considerably and significantly lower rates of acute service utilization than the control group, including 23% fewer hospitalizations, 26% fewer inpatient bed days, 22% fewer emergency department visits, 44% fewer heart failure hospitalizations, 70% fewer 30-day readmissions, and 45% fewer SNF bed days. Claims costs were 1,792 dollars per person lower in the intervention group than in the control group (inclusive of intervention costs), and the return on investment was calculated to be 2.31.

CONCLUSION

The study demonstrates that a commercially delivered heart failure disease-management program significantly reduced hospitalizations, emergency department visits, and SNF days. The intervention group had 17% lower costs than the control group; when intervention costs were included, the intervention group had 10% lower costs.

Mechanisms and management of hypertensive heart disease: from left ventricular hypertrophy to heart failure

Hypertensive heart disease (HHD) is a spectrum of abnormalities that represents the accumulation of a lifetime of functional and structural adaptations to increased blood pressure load. Left ventricular hypertrophy (LVH), increasing vascular and ventricular stiffness,and diastolic dysfunction are prominent intermediate features of this syndrome that operate in parallel with ischemic heart disease and ultimately cause heart failure (HF) if inadequately treated. Outcomes in HHD and HF are improved by antihypertensive drugs at any stage of the condition. This review describes an integrated model of the natural history, pathogenesis, and drug treatment of hypertensive heart disease that is consistent with the recommendations of the Seventh Report of the Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure, including an important modification to the HF guideline published by the American College of Cardiology and the American Heart Association that includes LVH and diastolic dysfunction as treatable conditions within the HHD-HF continuum.

Left Ventricular Assist Device as Destination for Patients Undergoing Intravenous Inotropic Therapy

Background— Left ventricular assist devices (LVADs) have improved survival in patients with end-stage heart failure. Compared with previous trials, the Randomized Evaluation of Mechanical Assistance in Treatment of Chronic Heart Failure (REMATCH) trial enrolled patients with more advanced heart failure and high prevalence of intravenous inotropic therapy. This study analyzes, on a post hoc basis, outcomes in patients undergoing inotropic infusions at randomization.

Methods and Results— Of 129 patients randomized, 91 were receiving intravenous inotropic therapy at randomization to LVAD or optimal medical management (OMM). Mean systolic pressure was 100 versus 107 mm Hg in those not receiving inotropes, serum sodium was 134 versus 137 mEq/L, and left ventricular ejection fraction was 17% for both groups. LVADs improved survival throughout follow-up for patients undergoing baseline inotropic infusions ( P =0.0014); for the LVAD group versus the OMM group, respectively, 6-month survival was 60% versus 39%, 1-year survival rates were 49% versus 24%, and 2-year survival rates were 28% versus 11%. For 38 patients not undergoing inotropic infusions, 6-month survival was 61% for those with LVADs and 67% for those with OMM, whereas 1-year rates were 57% and 40%, respectively ( P =0.55). Quality-of-life scores for survivors improved. Median days out of hospital for patients on inotropic therapy at randomization were 255 with LVAD and 105 with OMM.

Conclusions— Despite severe compromise, patients undergoing inotropic infusions at randomization derived major LVAD survival benefit with improved quality of life. Patients not undergoing inotropic infusions had higher survival rates both with and without LVAD, but differences did not reach significance. Future studies should prespecify analyses of inotropic and other therapies to determine how disease severity and parallel medical treatment influence the benefits offered by mechanical circulatory support.

[Medical treatment of acute heart failure]

Medical treatment of acute decompensated heart failure has little changed in the last years, except with the advent of non-invasive ventilation. Doppler-echocardiography and BNP dosing have simplified the diagnostic approach and limited the need for invasion evaluation. Vasodilators remain probably underused whereas some doubts have emergency regarding the safety of positive inotropes. Analysis of the hemodynamic profile is mandatory for an optimal management of these patients. The next decade will be that of morbimortality trials in this common form of heart failure with severe prognosis.

Hospice as an alternative model of care for older patients with end-stage heart failure

The end of life for patients with end-stage heart failure is often characterized by pain, shortness of breath, and diminished quality of life, indicating a lack of adequate care necessary for patients to experience a good death. The vast majority of those who die from heart failure are 65 or older and potentially eligible for the Medicare Hospice Benefit. Yet, only about 10% of patients with end-stage heart failure actually enroll in hospice programs. Lack of enrollment into hospice has been attributed to a variety of factors including a lack of understanding of the availability of hospice as an option for those with heart failure. While improving models of care for patients with heart failure has been of great interest during the last two decades, little is known about the benefits of hospice as a model for care in patients with end-stage heart failure. Nursing must participate in research that explores options of either improving current models of care or developing new and improved models of care for patients with heart failure.

Continuous Renal Replacement Therapy for Management of Overhydration in Heart Failure

An estimated 4.8 million Americans are diagnosed with heart failure. Of those, 5% to 10% meet criteria for the refractory state of the disease. While therapeutic interventions continue to evolve with the changing conceptualization of heart failure pathophysiology, overhydration and its deleterious sequelae remain a problem for those in the refractory state. The incidence of heart failure continues to rise in older individuals. As baby-boomers age across America, greater focus on new, more effective therapies must be considered for treatment of this disease. Continuous renal replacement therapy (CRRT) is one such treatment. The gentle removal of fluid and metabolites while maintaining electrolyte balance helps reduce the effects of overhydration in patients with heart failure. Increasing use of the therapy in the refractory state of heart failure is generating support for early initiation as it continues to demonstrate positive effects. Reduction in edema, attenuation of the sympathoadrenal cascade, and improved respiratory status have all been documented using the therapy. The intent of this article is to provide information for advanced practice nurses and direct care providers regarding CRRT for the treatment of heart failure refractory to typical therapy.

The problem of decompensated heart failure: nomenclature, classification, and risk stratification

Despite its high prevalence and significant rates of associated morbidity and mortality, the syndrome of decompensated heart failure remains poorly defined and vastly understudied. Few high-quality epidemiologic studies, randomized controlled trials, or published guidelines are available to guide the management of this complex disease. In addition, there is no consensus definition of the clinical problem that it presents, no agreed upon nomenclature to describe its clinical features, and no recognized classification scheme for its patient population; all of which has contributed to the lack of therapeutic development in this critical arena of cardiovascular disease. This review outlines the scope of the problem and proposes a system of nomenclature and classification sufficiently simple for general acceptance among clinicians while still encompassing the heterogeneity of the patient population. It also defines the current understanding of strategies for risk stratification in the setting of decompensated heart failure.

Prevalence of chronic heart failure in Southwestern Europe: the EPICA study

AIM

To estimate the prevalence of chronic heart failure (CHF) in mainland Portugal in 1998.

METHODS AND POPULATION

A community-based epidemiological survey involving subjects attending primary care centres selected by a combined two-stage sampling and stratified procedure. General practitioners (GPs) randomly selected in proportion to the population of the District, evaluated subjects attending primary care centres aged over 25 years, recruited consecutively and stratified by age. CHF cases were identified according to the Guidelines of the European Society of Cardiology for CHF diagnosis.

RESULTS

5434 eligible subjects were evaluated by 365 GPs; 551 patients with CHF were identified. The overall prevalence and 95% CI of CHF in mainland Portugal is 4.36% (3.69-5.02%), 4.33% in males (3.19-5.46%), and 4.38% in females (3.64-5.13%). Age-specific CHF prevalence was as follows: 1.36% in the 25-49 years-old group (0.39-2.33%), 2.93% in the 50-59 years-old group (5.58-9.37%), 7.63% in the 60-69 years-old group (5.58-9.37%), 12.67% in the 70-79 years-old group (10.73-14.6%), and 16.14% in group over 80 years old (13.81-18.47%). The prevalence of CHF due to systolic dysfunction was 1.3% and the prevalence of CHF with normal systolic function was 1.7%.

CONCLUSIONS

The overall prevalence of CHF in Portugal was slightly higher than that of other European studies and increases sharply with age. The prevalence of CHF due to systolic dysfunction is very similar to that reported by other recent European studies. The differences found may correspond to differences in methodology rather than actual differences in the population.

Therapeutic options and heart failure survival score predictability in an academic heart failure center: an analysis of 120 consecutive patients during a 1-year period

BACKGROUND

the incidence and prevalence of patients with advanced heart failure is increasing worldwide and the number of cardiac transplantations remains limited.

AIMS

it was the aim of the study to describe our experience with the increasing number of available medical, interventional and cardiac surgery options, and to assess heart failure survival score predictability in an academic heart failure center within a 1-year follow-up.

METHODS AND RESULTS

in all patients who were referred for cardiac transplant evaluation within a 12-month period between April 1998 and March 1999 at our Interdisciplinary Heart Failure and Transplant Program, our team assessed all medical interventions as well as interventional and surgical treatment options that were available, based on the clinical profile on initial presentation. In 92% of the 120 patients referred for cardiac transplantation evaluation, drug therapy could be optimized. A considerable number of patients could be subjected to an organ-preserving intervention or surgery, either PTCA (n=11), CABG (n=4), valve repair (n=7), multisite pacing (n=7), or partial ventricular resection (n=5). Only a small group of patients with the worst heart failure survival score were listed for heart transplantation (n=17) or received a ventricular assist device (n=3).

CONCLUSIONS

within a contemporary cohort of advanced heart failure patients, only a small number of patients will undergo cardiac transplantation, which is predictable by the heart failure survival score. Most patients will undergo optimized medical therapy and a considerable number will be subjected to interventional or surgical treatment options.

Epidemiology of heart failure

The enormous impact of the growing epidemic of heart failure mandates the development of easily accessible registries for patients with all classes of CHF, particularly those with advanced heart failure. It also is important to compile data from patients not enrolled in randomized trials to truly appreciate the natural history of this disease. The continued aging of the United States population will surely lead to continual increase in the prevalence of heart failure and its impact on the health care economy. It also is important to develop methods to reliably identify patients with systolic versus primary diastolic dysfunction to better understand the demographics, risk factors, and natural history of diastolic dysfunction. Increased attention clearly is warranted to better understand the demographics and risk factors for development CHF and to help devise strategies to reduce the morbidity, mortality, and economic impact of this disease.

Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness (ESCAPE): design and rationale

BACKGROUND

There is little information about how to adjust pharmacologic agents in the treatment of patients with advanced congestive heart failure (CHF). Some studies have suggested that use of pulmonary artery catheterization to guide reductions in filling pressures may improve outcomes for patients with heart failure who are hospitalized with evidence of elevated filling pressures. However, there is no consensus regarding the true utility of this strategy. A randomized clinical trial is needed to test the safety, efficacy, and treatment benefit of pulmonary artery catheterization in patients with advanced CHF.

STUDY DESIGN

The Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness (ESCAPE) trial is a multicenter, randomized trial designed to test the long-term safety and efficacy of treatment guided by hemodynamic monitoring and clinical assessment versus that guided by clinical assessment alone in patients hospitalized with New York Heart Association class IV CHF. Five hundred patients will be randomly assigned to receive either medical therapy guided by a combination of clinical assessment and hemodynamic monitoring (PAC arm) or medical therapy guided by clinical assessment alone (CLIN arm). The primary end point of ESCAPE will be the number of days that patients are hospitalized or die during the 6-month period after randomization. Secondary end points will include changes in mitral regurgitation, peak oxygen consumption, and natriuretic peptide levels. Other secondary end points will be pulmonary artery catheter-associated complications, resource utilization, quality of life measures, and patient preferences regarding survival.

IMPLICATIONS

The primary goal of ESCAPE will be to provide information about the utility of the pulmonary artery catheter in patients with advanced heart failure, independent of various treatment approaches used by individual physicians. In addition, this study will define current outcomes for this severely compromised population.

Cost effectiveness of bisoprolol in the treatment of chronic congestive heart failure in Sweden: analysis using data from the Cardiac Insufficiency Bisoprolol Study II trial

OBJECTIVE

To investigate the cost effectiveness of adding the beta-blocker bisoprolol to standard treatment in patients with congestive heart failure (CHF).

DESIGN AND SETTING

A cost-effectiveness study was based on the Cardiac Insufficiency Bisoprolol Study II (CIBIS-II), a randomised clinical trial investigating the efficacy of adding bisoprolol to standard therapy of CHF. The cost-effectiveness analysis was carried out from a societal perspective.

METHODS

Health effects were measured in terms of years of life gained. On the cost side, treatment costs for pharmaceuticals and hospitalisations were included. Data on healthcare resource consumption from CIBIS-II were used and were combined with average Swedish retail prices for medicines, and average costs for hospitalisations based on hospital admissions, in the base case. The costs of added years of life, i.e. consumption net of production during life-years gained were also included.

RESULTS

If costs of added years of life were not included, then bisoprolol therapy increased life expectancy at an incremental cost of Swedish kronor (SEK) 13 094 (1999 values) per year of life gained. If costs of added years of life were included, then the incremental cost-effectiveness ratio of bisoprolol therapy was SEK 168 858 per year of life gained.

CONCLUSIONS

For patients with CHF with the characteristics of those in CIBIS-II, the cost effectiveness of bisoprolol therapy compares favourably with that of other cardiovascular therapies.

The AHF SCENE II Preceptorship Program: rationale and design of an educational program to optimize management of advanced heart failure

Advanced heart failure requires specialized treatment to improve symptoms, increase survival, and reverse or slow disease progression. The Advanced Heart Failure Shared Clinical Experiences Network, or AHF SCENE, was founded in 1995 to provide small groups of health care professionals with better advanced heart failure management strategies by sharing clinical experiences from centers treating large numbers of patients. The original AHF SCENE program has since been modified to provide health care professionals with more information on current strategies for advanced heart failure management and to better serve the educational needs of professionals who care for these patients. AHF SCENE II promotes new methods, programs, procedures, and pharmacologic interventions and also describes strategies for tracking and improving clinical and economic outcomes in the management of advanced heart failure. AHF SCENE II supports the understanding that rapid, aggressive medical management is essential and is more effective in the context of a well designed program that spans the continuum of care. (c)2000 by CHF, Inc.

Incidence, clinical and etiologic features, and outcomes of advanced chronic heart failure: the EPICAL Study. Epidémiologie de l'Insuffisance Cardiaque Avancée en Lorraine

OBJECTIVES

Characterize the incidence, clinical and etiologic features and outcomes of advanced congestive heart failure.

BACKGROUND

This condition is frequent, severe and costly, yet no population-based epidemiological data are available that take into account modern advances in diagnosis and therapy.

METHODS

The EPICAL (Epidémiologie de l'Insuffisance Cardiaque Avancée en Lorraine) study was based on a comprehensive registration of patients with ACHF (defined as hospital admission for presence of NYHA class III or IV symptoms, radiological and/or clinical signs of pulmonary congestion and/or signs of peripheral edema, left ventricular ejection fraction <30% or a cardiothoracic ratio >60%) in patients aged 20-80 years during year 1994, in the community of the Lorraine region in France (n = 1,592,263). Average follow-up for readmission to hospital and mortality was 18 months (12-24 months).

RESULTS

From 2,576 registered patients, 499 were enrolled into the study among which, 358 were new presentations. This represents a crude incidence rate of 225 per million. 46.3% had a coronary heart disease. One-year mortality rate was 35.4% and the rate of mortality and/or readmission to hospital was 81%. Patients were admitted to hospital 2.05 times per year (64% of these for worsening heart failure), spending 27.6 days per year in hospital. Twenty received a heart transplant (4%). On discharge, 74.8% were using ACE inhibitors and 49.6% digitalis.

CONCLUSIONS

Mortality and hospitalization rate of advanced CHF remain very high despite recent therapeutic progress. Major therapeutic and managed-care research is required.