Canadian Cardiovascular Society Consensus Conference recommendations on heart failure update 2007: Prevention, management during intercurrent illness or acute decompensation, and use of biomarkers

Underrepresentation of individuals 80 years of age and older in chronic disease clinical practice guidelines

OBJECTIVE

To determine whether Canadian clinical practice guidelines (CPGs), and the evidence used to create CPGs, include individuals 80 years of age and older.

DESIGN

Descriptive analysis of 14 CPGs for 5 dominant chronic conditions (diabetes, hypertension, heart failure, osteoporosis, stroke) and descriptive analysis of all research-based references with human participants in the 14 guidelines.

MAIN OUTCOME MEASURES

To identify recommendations for individuals 65 years of age and older or 80 years of age and older and for those with multiple chronic conditions.

RESULTS

Although 12 of 14 guidelines provided specific recommendations for individuals 65 years of age and older, only 5 provided recommendations for frail older individuals (≥ 80 years). A total of 2559 studies were used as evidence to support the recommendations in the 14 CPGs; 2272 studies provided the mean age of participants, of which only 31 (1.4%) reported a mean age of 80 years of age and older.

CONCLUSION

There is very low representation of individuals in advanced old age in CPGs and in the studies upon which these guidelines are based, calling into question the applicability of current chronic disease CPGs to older individuals. The variety of medical and functional issues occurring in the elderly raises the concern of whether or not evidence-based disease-specific CPGs are appropriate for such a diverse population.

Cardiorenal syndrome: an unsolved clinical problem

The clinical relevance of the bidirectional cross-talk between heart and kidney is increasingly recognized. However, the optimal approach to the management of kidney dysfunction in heart failure remains unclear. The purpose of this article is to outline the most plausible pathophysiologic theories that attempt to explain the renal impairment in acute and chronic heart failure, and to review the current treatment strategies for these situations.

Evaluation of a web-based interactive heart failure patient simulation: a pilot study

BACKGROUND

There is a gap between the evidence and the management of patients with heart failure. To improve knowledge uptake, we have developed a web-based heart failure simulation that was designed to be fun, realistic, and interactive. We sought to determine whether clinicians will use the web-based simulation of patients with heart failure and whether it will improve their knowledge compared to the latest heart failure guidelines.

METHODS

Internists were asked to manage 3 simulated patients with heart failure. We measured knowledge before and after the simulation, analyzed users' performance managing the cases, and assessed their satisfaction with the website.

RESULTS

With 10 internists, there was no change in knowledge seen with 69% in before and after test scores. There was a trend to improvement in the performance scores in how users managed the cases with 77.3% in the first case, 81.5% in the second case (P = 0.21 compared to the first score), and 85.0% in the third case (P = 0.02 compared to the first score). The participants' satisfaction with the website was high.

CONCLUSIONS

In this pilot study, no change in short-term knowledge was seen with this web-based heart failure patient simulation. There was an improvement in management of simulated cases and user satisfaction was high.

Ultrafiltration in the management of acute decompensated heart failure

PURPOSE OF REVIEW

Admissions to hospital for acute decompensated heart failure continue to increase and represent a significant burden on both patients' and healthcare resources. The majority of these admissions are for the control of volume overload; however, standard treatment with intravenous diuretics is not always effective and can lead to increased renal morbidity. One alternative to standard therapy is mechanical fluid removal with ultrafiltration, this review will highlight the current evidence and efficacy regarding ultrafiltration use in acute heart failure.

RECENT FINDINGS

Multiple recent clinical trials have demonstrated the safety and feasibility of ultrafiltration in the management of acute heart failure. Ultrafiltration may be more effective at removing fluid than standard diuretic therapy and has been associated with beneficial long-term results. However, it remains to be determined whether ultrafiltration is truly nephroprotective and when and how this therapy is best utilized.

SUMMARY

Ultrafiltration is an attractive alternative to standard diuretic therapy in the management of volume overload from acute heart failure. Further research is needed to confirm the cost-effectiveness and to determine long-term impacts on morbidity and mortality.

Quality of congestive heart failure care: assessing measurement of care using electronic medical records

OBJECTIVE

To study the feasibility of using electronic medical record (EMR) data from the Deliver Primary Healthcare Information (DELPHI) database to measure quality of care for patients with congestive heart failure (CHF) in primary care and to determine the percentage of patients with CHF receiving the recommended care.

DESIGN

Items listed on the Ontario Ministry of Health and Long-Term Care Heart Failure Patient Care Flow Sheet (CHF flow sheet) were assessed and measured using EMRs of patients diagnosed with CHF between October 1, 2005, and September 30, 2008.

SETTING

Ten primary health care practices in southwestern Ontario.

PARTICIPANTS

Four hundred eighty-eight patients who were considered to have CHF because at least 1 of the following was indicated in their EMRs: an International Classification of Diseases billing code for CHF (category 428), an International Classification of Primary Care diagnosis code for heart failure (ie, K77), or "CHF" reported on the problem list.

MAIN OUTCOME MEASURES

Number of CHF flow sheet items that were measurable using EMR data from the DELPHI database. Percentage of patients with CHF receiving required quality-of-care items since the date of diagnosis.

RESULTS

The DELPHI database contained information on 60 (65.9%) of the 91 items identified using the CHF flow sheet. The recommended tests and procedures were recorded infrequently: 55.5% of patients with CHF had chest radiographs; 32.6% had electrocardiograms; 32.2% had echocardiograms; 30.5% were prescribed angiotensin-converting enzyme inhibitors; 20.9% were prescribed β-blockers; and 15.8% were prescribed angiotensin II receptor blockers.

CONCLUSION

Low frequencies of recommended care items for patients with CHF were recorded in the EMR. Physicians explained that CHF care was documented in areas of the EMR that contained patient identifiers, such as the encounter notes, and was therefore not part of the DELPHI database. Extractable information from the EMR does not provide a complete picture of the quality of care provided to patients with CHF.

Targeting success in heart failure: evidence-based management

Heart failure (HF) is a common condition in primary care with 1% of the population self-reporting this condition. Mortality is substantial, approaching 40% to 50% over 5 years. Heart failure is a complex syndrome in which abnormal heart function results in, or increases the subsequent risk of, clinical symptoms and signs of low cardiac output or pulmonary or systemic congestion.¹ This article will present some practical tips for managing HF.²

Primary prevention of heart failure: an update

PURPOSE OF REVIEW

The prevalence of heart failure is increasing world-wide. Primary prevention is essential. There are no trials targeting primary prevention. This review will focus on recently published studies that support drug therapy and lifestyle modification of high risk patients.

RECENT FINDINGS

Recent meta-analyses confirm the beneficial effect of ACE-inhibitors, angiotensin-receptor blockers, and diuretics and/or beta blockers in the prevention of heart failure. However, heart failure is increased in patients receiving calcium channel blockers when compared with those receiving ACE-Is and beta blockers. High adherence to antihypertensive therapy results in a significant reduction in heart failure. Targeting a systolic blood pressure of less than 120 mmHg compared with less than 140 mmHg in diabetic hypertensive patients does not appear to decrease the development of heart failure. Not smoking, maintaining a healthy weight, performing regular exercise, and maintaining a healthy diet decrease the incidence of heart failure.

SUMMARY

Utilization of antihypertensive agents appears to be the best global strategy for the prevention of heart failure. ACE-inhibitors and angiotensin-receptor blockers remain excellent first line agents. A large proportion of heart failure risk is due to modifiable factors, which need to be identified and controlled. Smoking confers up to a two-fold risk for the development of heart failure in the elderly and should be aggressively targeted.

Hyponatremia in heart failure: revisiting pathophysiology and therapeutic strategies

Hyponatremia is frequently encountered in patients with heart failure (HF), and its association with adverse outcomes is well-established in this population. While hyponatremia is an independent marker for severity of HF, it is not certain whether it has a causal impact on the progression of the disease. There are no universally accepted consensus guidelines regarding therapeutic strategies for HF-associated hyponatremia and volume overload; current societal guidelines do not address management of this complication. Whereas thiazide diuretics are known to induce or worsen hyponatremia in this setting through a number of mechanisms, loop diuretics can be considered a readily available first-line pharmacologic therapy. Consistent with pathophysiology of the disease and mechanisms of action of loop diuretics, available clinical evidence supports such an approach provided that patients can be closely monitored. Use of vasopressin receptor antagonists is an emerging therapeutic strategy in this setting, and the efficacy of these agents has so far been shown in a number of clinical studies. These agents can be reserved for patients with HF in whom initial appropriate loop diuretic therapy fails to improve serum sodium levels.

[Diversity in spite of standards: the special features of NDGMs]

For seven years the German National Disease Management Guidelines Programme (NDMG Programme) has been supported by its funding bodies: the German Medical Association, the National Association of Statutory Health Insurance Physicians, and the Association of Scientific Medical Societies. The objectives of the NDMG Programme are to develop and to implement comprehensive national clinical guidelines for the management of selected illnesses. Key points of NDMG methodology are the strict adherence to the principles of evidence-based medicine as well as the avoidance of contradictory recommendations by means of neutrally facilitated consensus rounds. Despite the standardised NDMG methodology each guideline has individual structural and content features that make it unique. For example, the complex illness type 2 diabetes is presented in topic- and problem-oriented NDMG modules. For unipolar depression, the NDMG was simultaneously developed as a S3 guideline. Furthermore each NDMG group was faced with its own content-based challenges. For instance, in the case of the NDMG Low-back Pain the guideline group intensely and controversially discussed the definition of unspecific low-back pain. The NDMG Asthma does not solely address adults, but also children and adolescents, and the NDMG Heart Failure for the first time covers other health care relevant aspects such as multimorbidity and psychosocial factors in detail. The following article aims to deliver insight into the diversity of the development of National Disease Management Guidelines and to demonstrate the complexity of guideline development.

Managing beta-blockers in acute heart failure: when to start and when to stop?

The role of beta-blockers in heart failure has been long debated. Data from chronic heart failure studies clearly indicate that beta-blockers save lives. However, data concerning use of beta-blockers in patients with acute heart failure are limited, and only recently have emerged to help guide therapy. In this review, we provide an overview of when to stop and when to start beta-blockers in patients with acute heart failure.

The 2010 Canadian Cardiovascular Society guidelines for the diagnosis and management of heart failure update: Heart failure in ethnic minority populations, heart failure and pregnancy, disease management, and quality improvement/assurance programs

Since 2006, the Canadian Cardiovascular Society heart failure (HF) guidelines have published annual focused updates for cardiovascular care providers. The 2010 Canadian Cardiovascular Society HF guidelines update focuses on an increasing issue in the western world - HF in ethnic minorities - and in an uncommon but important setting - the pregnant patient. Additionally, due to increasing attention recently given to the assessment of how care is delivered and measured, two critically important topics - disease management programs in HF and quality assurance - have been included. Both of these topics were written from a clinical perspective. It is hoped that the present update will become a useful tool for health care providers and planners in the ongoing evolution of care for HF patients in Canada.

Managing anemia in patients with chronic heart failure: what do we know?

Anemia is common in patients with chronic heart failure (HF) with an incidence ranging from 4% to 55% depending on the studied population. Several studies have highlighted that the prevalence of anemia increases with worsening heart failure as reflected by New York Heart Association classification. Additionally, several epidemiological studies have highlighted its role as a prognostic marker, linking it to worse outcomes including; malnutrition, increased hospitalizations, refractory heart failure and death. The pathophysiology of anemia is multifactorial and related to various factors including; hemodilution, iron losses from anti-platelet drugs, activation of the inflammatory cascade, urinary losses of erythropoietin and associated renal insufficiency. There are a host of epidemiological studies examining HF outcomes and anemia, but only a few randomized trials addressing this issue. The purpose of this article is to review the literature that examines the interrelationship of anemia and congestive HF, analyzing its etiology, impact on outcomes and also the role of associated kidney disease as well as cardiorenal syndrome both as a marker of morbidity and mortality.

Need for a unified decision-making tool for ultrafiltration therapy in heart failure; call for action

Although ultrafiltration portends several theoretical advantages over the standard therapy for acute decompensated heart failure, it might not be the optimal treatment for all patients presenting with an episode of decompensation. It is not yet clear how to prospectively identify the subset of patients that would benefit from this therapeutic modality. Based on the pathophysiologic mechanisms underlying acute decompensated heart failure, early ultrafiltration therapy can be an appropriate initial management strategy for those patients with diuretic resistance whose associated renal dysfunction is related to hemodynamic changes rather than a structural abnormality. In the absence of widely accepted consensus guidelines, ultrafiltration use is currently subject to considerable variations among physicians. A clinical tool (eg, a scoring system) that is based on the individual patient's characteristics is therefore needed to prospectively identify the appropriate candidates for this therapy. Using this system is likely to portend better outcomes while helping to avoid unnecessary exposure to potential risks of extracorporeal therapies.

Factors related to time to admission to specialized multidisciplinary clinics in patients with congestive heart failure

BACKGROUND

Congestive heart failure (CHF) is a common cause of hospitalization and has a poor prognosis. Specialized multidisciplinary clinics are effective in the management of CHF.

OBJECTIVES

To measure time of admission to the specialized clinics and explore factors related to the time of admission to these clinics.

METHODS

Patients who were newly admitted to one of six CHF multidisciplinary clinics in the province of Quebec were enrolled in the study. Data were collected from the common clinical database used at these clinics as well as from questionnaires administered to the patients.

RESULTS

A total of 531 patients with a mean age of 65.9 years were enrolled. Only 26% were women. The median duration of disease before admission to the CHF clinic was 1.2 years. The majority of patients (62%) were referred by a cardiologist or an internist, while 24% were referred by other specialists, and 14% by general practitioners. One-fifth of patients did not have regular follow-up for their CHF before being admitted to the clinic. Factors associated with shorter disease duration at admission to the clinic were referral by a specialist, not having regular medical follow-up for CHF, having a higher income and having visited the emergency room for CHF.

CONCLUSION

There may be a need to improve dissemination of information regarding availability and benefits of CHF clinics and criteria for referral.

Primary prevention of heart failure: what is the evidence?

PURPOSE OF REVIEW

Heart failure is a worldwide epidemic. Aggressive treatment of patients at risk for heart failure is important. There are no trials targeting primary prevention of heart failure. However, there is trial data demonstrating that treatment of patients with atherosclerotic vascular disease, hypertension, and diabetes can prevent heart failure.

RECENT FINDINGS

Several recent trials further expand our knowledge of how to best treat high-risk patients. Treatment of hypertensive patients over age 80 with indapamide and an ACE-inhibitor if needed can significantly reduce heart failure and mortality. There is no additional benefit from the combination of an ACE-inhibitor and angiotensin receptor blocker therapy in patients with vascular disease or high-risk diabetic patients. Continued blood pressure control is necessary to maintain beneficial cardiovascular outcomes.

SUMMARY

Identification and treatment of patients at high risk can prevent the development of heart failure and reduce heart failure hospitalization. Thiazide diuretics, ACE-inhibitors or angiotensin receptor blockers if ACE-inhibitor-intolerant are preferred first-line agents.

Canadian Cardiovascular Society Consensus Conference guidelines on heart failure, update 2009: diagnosis and management of right-sided heart failure, myocarditis, device therapy and recent important clinical trials

The Canadian Cardiovascular Society published a comprehensive set of recommendations on the diagnosis and management of heart failure in January 2006. Based on feedback obtained through a national program of heart failure workshops and through active solicitation of stakeholders, several topics were identified because of their importance to the practicing clinician. Topics chosen for the present update include best practices for the diagnosis and management of right-sided heart failure, myocarditis and device therapy, and a review of recent important or landmark clinical trials. These recommendations were developed using the structured approach for the review and assessment of evidence adopted and previously described by the Society. The present update has been written from a clinical perspective to provide a user-friendly and practical approach. Specific clinical questions that are addressed include: What is right-sided heart failure and how should one approach the diagnostic work-up? What other clinical entities may masquerade as this nebulous condition and how can we tell them apart? When should we be concerned about the presence of myocarditis and how quickly should patients with this condition be referred to an experienced centre? Among the myriad of recently published landmark clinical trials, which ones will impact our standards of clinical care? The goals are to aid physicians and other health care providers to optimally treat heart failure patients, resulting in a measurable impact on patient health and clinical outcomes in Canada.

Current treatment options for early management in acute decompensated heart failure

Acute decompensated heart failure (ADHF) is a common syndrome that precedes over 100,000 hospitalizations in Canada per year (with length of stay in excess of six to eight days), making this the most costly disorder for patients older than 65 years of age. Over 85% of ADHF patients present with shortness of breath and exhibit evidence of volume overload. These findings may be variable in elderly patients, which complicates diagnosis. In fact, even in experienced centres, diagnostic accuracy is less than 80%. Despite advances in the treatment of chronic heart failure, meaningful improvements in outcomes associated with ADHF are very few. The basic assessment and treatments have not changed (early parenteral diuretics, electrocardiographic and oxygen saturation monitoring, supplemental oxygen administration). The introduction of measurement of natriuretic peptides in those in whom the diagnosis is uncertain may reduced the error rate by over 50%. The use of vasodilator therapy in the absence of cardiogenic shock can lead to earlier amelioration of symptoms, especially in those who do not respond to initial diuretics. Repeated monitoring of vital signs, body weight, electrolytes and creatinine levels is essential to minimize the risk of side effects of treatments. Noninvasive ventilation may reduce the need for endotracheal intubation in patients with severe ADHF and hypoxia at rest. Once the initial phase of heart failure treatment is completed, then the clinician should begin to focus on maximization of chronic heart failure therapy and discharge planning.

Acute decompensated heart failure

Acute decompensated heart failure is the most common cause of hospitalization for patients older than 65 years of age. Although treatment of this condition has improved over the past two decades, the specific approach to patients in the acute setting has not evolved in the same way. A patient facing acute decompensation is experiencing a serious medical condition that is associated with a poor prognosis. In addition, acute decompensated heart failure results in significant costs to the health care system. Significant morbidity and mortality are associated with patients who are readmitted within a year of the first hospitalization. Because of this important problem, further research on improving the prognosis for this condition is warranted. The present article will focus on the risk factors associated with acute decompensation and the importance of this condition, both on prognosis and economics.

Cardiorenal syndrome in heart failure: a cardiologist's perspective

One of the most important comorbidities in heart failure is renal dysfunction. Diminished estimated glomerular filtration rate is a potent predictor of cardiovascular mortality and complications. On the other hand, worsening heart failure or acute decompensated heart failure can accelerate worsening of renal function--the so-called cardiorenal syndrome. Risk factors include hypertension, diabetes, elderly age, and prior history of heart or renal failure. The pathophysiology of the cardiorenal syndrome involves intrarenal hemodynamics, transrenal perfusion pressure and systemic neurohormonal factors. Clinical management of the patient with cardiorenal syndrome includes the challenge of diuretic resistance, which may involve correcting the underlying cause, combination diuretics or diuretic infusions. The key to improved outcome is the optimization of proven heart failure therapies. The use of vasodilator therapy is the current mainstay of treatment. Nesiritide, or recombinant B-type natriuretic peptide, has courted controversy regarding its role in cardiorenal syndrome. However, data are emerging that low doses appear to be renal-protective. Other more recent strategies include ultrafiltration, vasopressin antagonists and adenosine antagonists. All of these newer modalities promise more rapid volume removal, but their ultimate impact on survival or preservation of renal function is unknown at the present time. Because of the complex nature of these patients, and the compromised outcome, it is important that cardiologists, nephrologists and internists all work together toward the common goal of protecting the patient with cardiorenal syndrome, and use the best available evidence for management.

Differential diagnosis of acute dyspnea: the value of B natriuretic peptides in the emergency department

Congestive heart failure (CHF) is the main cause of acute dyspnea in patients presenting to an emergency department (ED) and is associated with high morbidity and mortality. B-type natriuretic peptide (BNP) is a polypeptide, released by ventricular myocytes in direct proportion to wall tension, which lowers renin-angiotensin-aldosterone activation. For the diagnosis of CHF, both BNP and the biologically inactive NT-proBNP have similar accuracy. Threshold values are higher in an elderly population, and in patients with renal dysfunction. They might also have a prognostic value. Studies have demonstrated that the use of BNP or NT-proBNP in dyspneic patients early following admission to the ED, reduced the time to discharge and total treatment cost. BNP and NT-proBNP should be available in every ED 24 h a day, because the literature strongly suggests the beneficial impact of an early appropriate diagnosis and treatment in dyspneic patients. The purpose of this review is to indicate recent developments in biomarkers of heart failure and to evaluate their impact on clinical use in the emergency setting.

AGREEing on Canadian cardiovascular clinical practice guidelines

The use of clinical practice guidelines (CPGs), particularly the routine implementation of evidence-based cardiovascular health maintenance and disease management recommendations, affords both expert and nonexpert practitioners the opportunity to achieve better, and at least theoretically similar, patient outcomes. However, health care practitioners are often stymied in their efforts to follow even well-researched and well-written CPGs as a consequence of contradictory information. The purposeful integration and harmonization of Canadian cardiovascular CPGs, regardless of their specific risk factor or clinical management focus, is critical to their widespread acceptance and implementation. This level of cooperation and coordination among CPG groups and organizations would help to ensure that their clinical practice roadmaps (ie, best practice recommendations) contain clear, concise and complementary, rather than contradictory, patient care information. Similarly, the application of specific tools intended to improve the quality of CPGs, such as the Appraisal of Guidelines for Research and Evaluation (AGREE) assessment tool, may also lead to improvements in CPG quality and potentially enhance their acceptance and implementation.

Clinical utility of serum N-terminal pro-B-type natriuretic peptide concentration for identifying cardiac disease in dogs and assessing disease severity

OBJECTIVE

To determine whether serum N-terminal pro-B-type natriuretic (NT-proBNP) concentration could be used to identify cardiac disease in dogs and to assess disease severity in affected dogs.

DESIGN

Cross-sectional study.

ANIMALS

119 dogs with mitral valve disease, 18 dogs with dilated cardiomyopathy, and 40 healthy control dogs.

PROCEDURES

Serum NT-proBNP concentration was measured with an ELISA validated for use in dogs. Results of physical examination, thoracic radiography, echocardiography, and serum biochemical analyses were recorded for dogs with cardiac disease.

RESULTS

Serum NT-proBNP concentration was significantly higher in dogs with cardiac disease than in control dogs, and a serum NT-proBNP concentration > 445 pmol/L could be used to discriminate dogs with cardiac disease from control dogs with a sensitivity of 83.2% and specificity of 90.0%. In dogs with cardiac disease, serum NT-proBNP concentration was correlated with heart rate, respiratory rate, echocardiographic heart size, and renal function. For dogs with cardiac disease, serum NT-proBNP concentration could be used to discriminate dogs with and without radiographic evidence of cardiomegaly and dogs with and without congestive heart failure.

CONCLUSIONS AND CLINICAL RELEVANCE

Results suggested that serum NT-proBNP concentration may be a useful adjunct clinical test for diagnosing cardiac disease in dogs and assessing the severity of disease in dogs with cardiac disease.

The Ability of Heart Failure Specialists to Accurately Predict NT-proBNP Levels Based on Clinical Assessment and a Previous NT-proBNP Measurement

Background:

The value of routine aminoterminal pro type B natriuretic peptide (NT-proBNP) measurements in outpatient clinics remains unknown.

Objectives:

We sought to determine the accuracy with which heart failure (HF) specialists can predict NT-proBNP levels in HF outpatients based on clinical assessment.

Methods:

We prospectively studied 160 consecutive HF patients followed in an outpatient multidisciplinary HF clinic. During a regular office visit, HF specialists were asked to estimate a patient’s current NT-proBNP level based upon their clinical assessment and all available information from their chart, including a previous NT-proBNP level (if available). NT-proBNP estimations were grouped into prognostic categories (<125, 125-1000, 1000-4998, or ≥4999 pg/mL) and comparisons made between actual and estimate values.

Results:

Overall, HF specialists estimated 67.5% of NT-proBNP levels correctly. After adjusting for clinical characteristics, knowledge of a prior NT-proBNP measurement was the only significant predictor of estimation accuracy (p=0.01). Compared to patients with a prior NT-proBNP level <125 pg/mL, physicians were 95% less likely to get a correct estimation in patients with the highest prior NT-proBNP level (≥4999 pg/mL).

Conclusion:

HF specialists are reasonably accurate at estimating current NT-proBNP levels based upon clinical assessment and a previous NT-proBNP level, if those levels were < 4999 pg/mL. Likely, initial but not routine NT-proBNP measurements are useful in outpatient HF clinics.

Biomarkers in heart failure management

PURPOSE OF REVIEW

Recent literature on the role of biomarkers in heart failure is reviewed, focusing on B-type natriuretic peptide.

RECENT FINDINGS

Knowledge of the processes which increase ventricular stress, thus increasing B-type natriuretic peptide, is key to appropriate utilization and interpretation of B-type natriuretic peptide levels. B-type natriuretic peptide is a useful adjunct to confirm or rule out heart failure. B-type natriuretic peptide is a robust prognostic indicator in all stages of heart failure, with prognostic significance in patients undergoing cardiac and noncardiac surgery, and in those with acute coronary syndromes. Serial B-type natriuretic peptide testing predicts outcomes in hospitalized patients with heart failure. The role of B-type natriuretic peptide in screening high-risk populations is promising, but its use in unselected populations is unclear. There is increasing evidence that the use of B-type natriuretic peptide to guide heart failure management is associated with improved clinical outcomes and reduced health costs.

SUMMARY

Biomarkers play an important role in heart failure, but there remain unanswered questions regarding optimization of their use. They should be used as an adjunct to, not replacement for, clinical assessment. Currently available B-type natriuretic peptide assays have limitations relating to clinical variability and assay specificity. Other neurohormonal, inflammatory and metabolic markers may add complementary information to that provided by currently available B-type natriuretic peptide assays.

Resting heart rate: a modifiable prognostic indicator of cardiovascular risk and outcomes?

A growing body of evidence from clinical trials and epidemiological studies has identified elevated resting heart rate as a predictor of clinical events. Proof of direct cause and effect is limited, because current drugs that lower heart rate (eg, beta-blockers) have multiple mechanisms of action. A new class of drug, selective I(f) inhibitors, is under investigation as a 'pure' heart rate-reducing medication and will help confirm if there is a causal link between elevated heart rate and cardiovascular outcomes. The present paper reviews the evidence for elevated heart rate as a cardiovascular risk factor and some of the current clinical trials testing this hypothesis.

Guidelines for the management of heart failure: differences in guideline perspectives

The development of clinical or practice guidelines is thought to be a successful strategy for improving quality of care. Accordingly, many professional organizations, societies, institutions of health care or policy, and even countries have published practice guidelines on a variety of topics, including heart failure.

Normal-sodium diet compared with low-sodium diet in compensated congestive heart failure: is sodium an old enemy or a new friend?

The aim of the present study was to evaluate the effects of a normal-sodium (120 mmol sodium) diet compared with a low-sodium diet (80 mmol sodium) on readmissions for CHF (congestive heart failure) during 180 days of follow-up in compensated patients with CHF. A total of 232 compensated CHF patients (88 female and 144 male; New York Heart Association class II–IV; 55–83 years of age, ejection fraction <35% and serum creatinine <2 mg/dl) were randomized into two groups: group 1 contained 118 patients (45 females and 73 males) receiving a normal-sodium diet plus oral furosemide [250–500 mg, b.i.d. (twice a day)]; and group 2 contained 114 patients (43 females and 71 males) receiving a low-sodium diet plus oral furosemide (250–500 mg, b.i.d.). The treatment was given at 30 days after discharge and for 180 days, in association with a fluid intake of 1000 ml per day. Signs of CHF, body weight, blood pressure, heart rate, laboratory parameters, ECG, echocardiogram, levels of BNP (brain natriuretic peptide) and aldosterone levels, and PRA (plasma renin activity) were examined at baseline (30 days after discharge) and after 180 days. The normal-sodium group had a significant reduction (P<0.05) in readmissions. BNP values were lower in the normal-sodium group compared with the low sodium group (685±255 compared with 425±125 pg/ml respectively; P<0.0001). Significant (P<0.0001) increases in aldosterone and PRA were observed in the low-sodium group during follow-up, whereas the normal-sodium group had a small significant reduction (P=0.039) in aldosterone levels and no significant difference in PRA. After 180 days of follow-up, aldosterone levels and PRA were significantly (P<0.0001) higher in the low-sodium group. The normal-sodium group had a lower incidence of rehospitalization during follow-up and a significant decrease in plasma BNP and aldosterone levels, and PRA. The results of the present study show that a normal-sodium diet improves outcome, and sodium depletion has detrimental renal and neurohormonal effects with worse clinical outcome in compensated CHF patients. Further studies are required to determine if this is due to a high dose of diuretic or the low-sodium diet.

Cardiac management during adjuvant trastuzumab therapy: recommendations of the Canadian Trastuzumab Working Group

Trastuzumab has been shown to be an effective therapy for women with breast cancer that overexpresses the human epidermal growth factor receptor 2 (her2) protein. In the pivotal metastatic breast cancer trials, cardiac dysfunction was observed in women treated with trastuzumab and chemotherapy. The incidence and severity of cardiac dysfunction was greatest among patients who received trastuzumab in combination with anthracycline-based therapy. Those findings influenced the design of subsequent trastuzumab trials to include prospective evaluations of cardiac effects and protocols for cardiac monitoring and management. The risk of cardiotoxicity has also driven efforts to develop non-anthracycline-based regimens for women with her2-positive breast cancers.With the increasing use of trastuzumab, particularly in the curative adjuvant setting, the need for a rational approach to the treatment and cardiac management of the relevant patient population is clear. The mandate of the Canadian Trastuzumab Working Group was to formulate recommendations, based on available data, for the assessment and management of cardiac complications during adjuvant trastuzumab therapy. The panel formulated recommendations in four areas: Risk factors for cardiotoxicity, Effects of various regimens, Monitoring, Management. The recommendations published here are expected to evolve as more data become available and experience with trastuzumab in the adjuvant setting grows.

Canadian Cardiovascular Society Consensus Conference guidelines on heart failure--2008 update: best practices for the transition of care of heart failure patients, and the recognition, investigation and treatment of cardiomyopathies

Heart failure is a clinical syndrome that normally requires health care to be provided by both specialists and nonspecialists. This is advantageous because patients benefit from complementary skill sets and experience, but can present challenges in the development of a common, shared treatment plan. The Canadian Cardiovascular Society published a comprehensive set of recommendations on the diagnosis and management of heart failure in January 2006, and on the prevention, management during intercurrent illness or acute decompensation, and use of biomarkers in January 2007. The present update builds on those core recommendations. Based on feedback obtained through a national program of heart failure workshops during 2006 and 2007, several topics were identified as priorities because of the challenges they pose to health care professionals. New evidence-based recommendations were developed using the structured approach for the review and assessment of evidence that was adopted and previously described by the Society. Specific recommendations and practical tips were written for best practices during the transition of care of heart failure patients, and the recognition, investigation and treatment of some specific cardiomyopathies. Specific clinical questions that are addressed include: What information should a referring physician provide for a specialist consultation? What instructions should a consultant provide to the referring physician? What processes should be in place to ensure that the expectations and needs of each physician are met? When a cardiomyopathy is suspected, how can it be recognized, how should it be investigated and diagnosed, how should it be treated, when should the patient be referred, and what special tests are available to assist in the diagnosis and treatment? The goals of the present update are to translate best evidence into practice, apply clinical wisdom where evidence for specific strategies is weaker, and aid physicians and other health care providers to optimally treat heart failure patients, resulting in a measurable impact on patient health and clinical outcomes in Canada.

Evidence for the use of B-type natriuretic peptides for screening asymptomatic populations and for diagnosis in primary care

OBJECTIVES

To determine the screening and diagnostic properties of BNP and NT-proBNP for heart failure in primary care.

DESIGN AND METHODS

We conducted a systematic review of randomized control trials and observational (cohort or case-control) studies of heart failure detection using B-type natriuretic peptides published in English from January 1989 to February 2005. We extracted or calculated sensitivity, specificity, positive and negative likelihood ratios, area under the receiver-operator characteristic curve and diagnostic odds ratio (DOR).

RESULTS

We included 17 studies (7 screening, 9 diagnosis in primary care or specialised clinic, 1 both). There was considerable heterogeneity within the study populations, reference standard for diagnosis, and B-type natriuretic peptide decision point. Sensitivity ranged from 26% to 98%; and specificity from 44% to 88%. For screening, the Diagnostic Odds Ratio (DOR) ranged from 2.7 to 29, and for diagnosis from 2.8 to 137.

CONCLUSIONS

The performance characteristics of B-type natriuretic peptides measurement are not suitable for screening asymptomatic patients. For diagnosis in primary care, low B-type natriuretic peptide values may be used to rule-out heart failure but, due to poor specificity, high values cannot be used to rule-in the condition.

N-Terminal Pro–B-Type Natriuretic Peptide Testing Improves the Management of Patients With Suspected Acute Heart Failure

BACKGROUND

The diagnostic utility of N-terminal pro-B-type natriuretic peptide (NT-proBNP) in heart failure has been documented. However, most of the data were derived from countries with high healthcare resource use, and randomized evidence for utility of NT-proBNP was lacking.

METHODS AND RESULTS

We tested the hypothesis that NT-proBNP testing improves the management of patients presenting with dyspnea to emergency departments in Canada by prospectively comparing the clinical and economic impact of a randomized management strategy either guided by NT-proBNP results or without knowledge of NT-proBNP concentrations. Five hundred patients presenting with dyspnea to 7 emergency departments were studied. The median NT-proBNP level among the 230 subjects with a final diagnosis of heart failure was 3697 compared with 212 pg/mL in those without heart failure (P<0.00001). Knowledge of NT-proBNP results reduced the duration of ED visit by 21% (6.3 to 5.6 hours; P=0.031), the number of patients rehospitalized over 60 days by 35% (51 to 33; P=0.046), and direct medical costs of all ED visits, hospitalizations, and subsequent outpatient services (US $6129 to US $5180 per patient; P=0.023) over 60 days from enrollment. Adding NT-proBNP to clinical judgment enhanced the accuracy of a diagnosis; the area under the receiver-operating characteristic curve increased from 0.83 to 0.90 (P<0.00001).

CONCLUSIONS

In a universal health coverage system mandating judicious use of healthcare resources, inclusion of NT-proBNP testing improves the management of patients presenting to emergency departments with dyspnea through improved diagnosis, cost savings, and improvement in selected outcomes.