Population Impact of Heart Failure and the Most Common Forms of Cancer

Internet-based cognitive behavior therapy for patients with heart failure and depressive symptoms: A proof of concept study

OBJECTIVE

The aim was (1) to describe the development of a guided internet-based CBT (ICBT) program adapted to patients with heart failure (HF) and (2) to evaluate the feasibility of the ICBT program in regard to depressive symptoms, the time used by health care providers to give feedback, and participants' perceptions of the ICBT program.

METHOD

A multi-professional team developed the program and seven HF patients with depressive symptoms were recruited to the study. The Patient Health Questionnaire-9 (PHQ-9) and the Montgomery Åsberg Depression Rating-Self-rating scale (MADRS-S) were used to measure depression, and patients were interviewed about their perceptions of the program.

RESULTS

Based on research in HF and CBT, a nine-week program was developed. The median depression score decreased from baseline to the end of the study (PHQ-9: 11-8.5; MADRS-S: 25.5-16.5) and none of the depression scores worsened. Feedback from health care providers required approximately 3h per patient. Facilitating perceptions (e.g. freedom of time) and demanding perceptions (e.g. part of the program demanded a lot of work) were described by the patients.

CONCLUSION

The program appears feasible and time-efficient. However, the program needs to be evaluated in a larger randomized study.

Copeptin as a biomarker in heart failure

Increased neurohormonal activation is a key feature of heart failure (HF). Copeptin is a surrogate marker for proarginine vasopressin and the prognostic value of copeptin has been reported for multiple disease states of both nonvascular and cardiovascular etiology. Elevated plasma copeptin in HF has been associated with adverse outcomes such as increased mortality, risk of hospitalization and correlates with the severity of HF. Copeptin may add prognostic information to already established predictors such as clinical variables and natriuretic peptides in HF. In addition, copeptin has been found to be a superior marker when compared with BNP and NT-proBNP in HF patients discharged after hospitalization caused by HF or myocardial infarction (MI). The optimal use of copeptin in HF remains unresolved and future appropriately sized and randomized trials must determine the role of copeptin in HF as a marker of adverse outcomes, risk stratification or as a target in biomarker-guided therapy with arginine vasopressin-antagonists in individualized patient treatment and everyday clinical practice.

Evaluation of the Alere NT-proBNP Test for Point of Care Testing

BACKGROUND

The object of the study was to evaluate the Alere point of care NT-proBNP assay as a suitable alternative to the central laboratory method to provide short test turnaround times in primary care.

METHOD

Blood NT-proBNP results obtained with the Alere assay (n = 100) were compared with serum NT-proBNP results analyzed by a Cobas 8000 analyzer (Roche Diagnostics, Mannheim, Germany).

RESULTS

There was a good agreement between the two NT-proBNP methods when used as a rule-out test for heart failure (HF) and the cut-off value <300 ng/l. A total of 47 samples gave values <300 ng/L with both methods and 51 samples gave values >300 with both methods. Thus, there was an agreement for 98% of the samples.

CONCLUSIONS

The study shows that the Alere NT-proBNP assay could be used in primary care permitting rapid NT-proBNP testing to rule out HF.

Emerging strategies to prevent heart failure after myocardial infarction

Congestive heart failure (CHF) remains a significant cause of death and disability in industrialized countries. Projections show that the prevalence of CHF will increase 46% from 2012 to 2030, resulting in over eight million adults with CHF in the United States. While substantial advances have been achieved in the treatment of CHF over the past two decades, CHF rivals cancer as a cause of mortality. Strategies focused on prevention of CHF should be emphasized to meaningfully impact the projected increase in CHF. Irrespective of the type of CHF, either systolic or diastolic, coronary artery disease has supplanted hypertension as the most prevalent cause for congestive heart failure, with a high rate of mortality and future hospitalizations. Since coronary artery disease plays a central role in the development of CHF, approaches to treat coronary artery disease and identification of patients at risk for recurrent myocardial infarction (RMI) are approaches to prevent development of CHF.            Subjects who sustain recurrent MI represent a particularly high-risk group for development of CHF. Despite the evolution of therapy for MI from thrombolytic therapy to primary percutaneous coronary intervention (PCI), RMI occurs in ~ 10% of patients in the first year after first MI, and 3 years after their first MI. In this review I explore emerging approaches to prevent RMI including the rationale for recent trials of complete revascularization at the time of MI, newly emerging biomarkers that have additive predictive value for identifying patients with high risk of CHF and death when using existing biomarkers. Finally, the paradigm of hematopoietic stem cell mobilization in MI leading to monocyte expansion and acceleration of atherosclerosis is discussed as an emerging approach to identify patients at high risk of RMI, CHF, and death after MI.

Dose-response relationship of total and leisure time physical activity to risk of heart failure: a prospective cohort study

BACKGROUND

The nature of the association between levels of physical activity and risk of heart failure is little known. We investigated nonlinear associations of total and leisure time physical activity with risk of heart failure.

METHODS AND RESULTS

In 1997, 39 805 persons without heart failure completed a questionnaire of lifestyle factors and medical history. We used Cox regression models to investigate total (adjusting for education and previous myocardial infarction) and direct (multivariable-adjusted) effects of self-reported total and leisure time physical activity on risk of heart failure of any cause and heart failure of nonischemic origin. Heart failure diagnoses were obtained until December 31, 2010. Higher leisure time physical activity was associated with lower risk of heart failure of any cause; hazard ratio of the total effect of leisure time physical activity was for fifth versus first quintile 0.54; 95% confidence interval was 0.44 to 0.66. The direct effect was similar. High total daily physical activity level was associated with lower risk of heart failure, although the effect was less pronounced than for leisure time physical activity (total effect hazard ratio, 0.81; 95% confidence interval, 0.69-0.95; fifth versus first quintile). A similar direct effect observed.

CONCLUSIONS

Leisure time physical activity was inversely related to risk of developing heart failure in a dose-response fashion. This was reflected in a similar but less pronounced association of total physical activity with risk of heart failure. Only part of the effects appeared to be mediated by traditional risk factors.

A systematic approach to chronic heart failure care: a consensus statement

The National Heart Foundation of Australia assembled an expert panel to provide guidance on policy and system changes to improve the quality of care for people with chronic heart failure (CHF). The recommendations have the potential to reduce emergency presentations, hospitalisations and premature death among patients with CHF. Best-practice management of CHF involves evidence-based, multidisciplinary, patient-centred care, which leads to better health outcomes. A CHF care model is required to achieve this. Although CHF management programs exist, ensuring access for everyone remains a challenge. This is particularly so for Aboriginal and Torres Strait Islander peoples, those from non-metropolitan areas and lower socioeconomic backgrounds, and culturally and linguistically diverse populations. Lack of data and inadequate identification of people with CHF prevents efficient patient monitoring, limiting information to improve or optimise care. This leads to ineffectiveness in measuring outcomes and evaluating the CHF care provided. Expanding current cardiac registries to include patients with CHF and developing mechanisms to promote data linkage across care transitions are essential. As the prevalence of CHF rises, the demand for multidisciplinary workforce support will increase. Workforce planning should provide access to services outside of large cities, one of the main challenges it is currently facing. To enhance community-based management of CHF, general practitioners should be empowered to lead care. Incentive arrangements should favour provision of care for Aboriginal and Torres Strait Islander peoples, those from lower socioeconomic backgrounds and rural areas, and culturally and linguistically diverse populations. Ongoing research is vital to improving systems of care for people with CHF. Future research activity needs to ensure the translation of valuable knowledge and high-quality evidence into practice.

Measurement of thirst in chronic heart failure- a review

Abstract Background: Thirst is a bothersome symptom of chronic heart failure (CHF) which impacts adversely on quality of life. Despite this, limited work has been done to investigate thirst as a symptom or to develop reliable and valid measures of thirst in CHF. The purpose of this manuscript is to establish which tools have been used in research to measure thirst in CHF. Methods: Medline, PubMed, CINAHL, and Scopus were searched using following key words thirst, heart failure, measure, scale, randomised controlled trials and multicentre studies. Results: The search discovered 37 studies of which 6 studies met the inclusion criteria. One study was a research abstract and five were full- text studies. To date, there are only three measurement tools utilised in studies examining thirst in CHF patients (Visual Analogue Scale, Numeric Rating Scale and Thirst Distress Scale). Conclusion: Thirst in CHF is measured in a non- systematic way. In recent studies, the VAS has been used to measure thirst intensity. While this measurement tool is very easy and quick to administer, using a uni-dimensional tool in conjunction with a multi-dimensional tool may be beneficial to capture all dimensions of thirst. In order to manage thirst efficiently, consistent measurement of thirst in CHF is vital.

Challenges facing early career academic cardiologists

Early career academic cardiologists currently face unprecedented challenges that threaten a highly valued career path. A team consisting of early career professionals and senior leadership members of American College of Cardiology completed this white paper to inform the cardiovascular medicine profession regarding the plight of early career cardiologists and to suggest possible solutions. This paper includes: 1) definition of categories of early career academic cardiologists; 2) general challenges to all categories and specific challenges to each category; 3) obstacles as identified by a survey of current early career members of the American College of Cardiology; 4) major reasons for the failure of physician-scientists to receive funding from National Institute of Health/National Heart Lung and Blood Institute career development grants; 5) potential solutions; and 6) a call to action with specific recommendations.

Mechanical unloading promotes myocardial energy recovery in human heart failure

BACKGROUND

Impaired bioenergetics is a prominent feature of the failing heart, but the underlying metabolic perturbations are poorly understood.

METHODS AND RESULTS

We compared metabolomic, gene transcript, and protein data from 6 paired samples of failing human left ventricular tissue obtained during left ventricular assist device insertion (heart failure samples) and at heart transplant (post-left ventricular assist device samples). Nonfailing left ventricular wall samples procured from explanted hearts of patients with right heart failure served as novel comparison samples. Metabolomic analyses uncovered a distinct pattern in heart failure tissue: 2.6-fold increased pyruvate concentrations coupled with reduced Krebs cycle intermediates and short-chain acylcarnitines, suggesting a global reduction in substrate oxidation. These findings were associated with decreased transcript levels for enzymes that catalyze fatty acid oxidation and pyruvate metabolism and for key transcriptional regulators of mitochondrial metabolism and biogenesis, peroxisome proliferator-activated receptor γ coactivator 1α (PGC1A, 1.3-fold) and estrogen-related receptor α (ERRA, 1.2-fold) and γ (ERRG, 2.2-fold). Thus, parallel decreases in key transcription factors and their target metabolic enzyme genes can explain the decreases in associated metabolic intermediates. Mechanical support with left ventricular assist device improved all of these metabolic and transcriptional defects.

CONCLUSIONS

These observations underscore an important pathophysiologic role for severely defective metabolism in heart failure, while the reversibility of these defects by left ventricular assist device suggests metabolic resilience of the human heart.

Incidence of first heart failure hospitalisation and mortality in Aboriginal and non-Aboriginal patients in Western Australia, 2000-2009

OBJECTIVES

To compare the incidence of first heart failure (HF) hospitalisation, antecedent risk factors and 1-year mortality between Aboriginal and non-Aboriginal populations in Western Australia (2000-2009).

METHODS

A population-based cohort aged 20-84 years comprising Aboriginal (n=1013; mean 54±14 years) and non-Aboriginal patients (n=16,366; mean 71±11 years) with first HF hospitalisation was evaluated. Age and sex-specific incidence rates and HF antecedents were compared between subpopulations. Regression models were used to examine 30-day and 1-year (in 30-day survivors) mortality.

RESULTS

Aboriginal patients were younger, more likely to reside in rural/remote areas (76% vs 23%) and to be women (50.6% vs 41.7%, all p<0.001). Aboriginal (versus non-Aboriginal) HF incidence rates were 11-fold higher in men and 23-fold in women aged 20-39 years, declining to about 2-fold in patients aged 70-84 years. Ischaemic and rheumatic heart diseases were more common antecedents of HF in younger (<55 years) Aboriginal versus non-Aboriginal patients (p<0.001). Hypertension, diabetes, chronic kidney disease, renal failure, chronic obstructive pulmonary disease, and a high Charlson comorbidity index (>=3) were also more prevalent in younger and older Aboriginal patients (p<0.001). Although 30-day mortality was similar in both subpopulations, Aboriginal patients aged<55 years had a 1.9 risk-adjusted hazard ratio (HR) for 1-year mortality (p=0.015).

CONCLUSIONS

Aboriginal people had substantially higher age and sex-specific HF incidence rate and prevalence of HF antecedents than their non-Aboriginal counterparts. HR for 1-year mortality was also significantly worse at younger ages, highlighting the urgent need for enhanced primary and secondary prevention of HF in this population.

The relationship of left ventricular mechanical dyssynchrony and cardiac sympathetic denervation to potential sudden cardiac death events in systolic heart failure

BACKGROUND

Patients with heart failure (HF) are at increased risk for left ventricular (LV) dyssynchrony which is associated with sudden cardiac death (SCD). This study examined the association of LV mechanical dyssynchrony and cardiac sympathetic denervation with potential SCD events in symptomatic patients with HF and reduced ejection fraction (HFrEF).

METHODS

Of the 917 HFrEF patients in ADMIRE-HF, 92 experienced adjudicated potential SCD events during a 17 months median follow-up. Propensity scores were used to assemble a matched cohort of 85 pairs of patients with and without potential SCD events. ADMIRE-HF subjects had rest gated SPECT Tc-99m and I-123 MIBG imaging. Perfusion images were processed using phase analysis software to derive phase standard deviation (SD), an index of mechanical dyssynchrony.

RESULTS

Of the 92 patients who experienced adjudicated potential SCD events 23 had SCD, 5 fatal myocardial infarction, 7 resuscitated cardiac arrest, 46 had appropriate ICD therapy, and 11 had sustained ventricular tachycardia. Patients who experienced potential SCD events had significantly wider phase SD than matched control patients (62.3 ± 2.4º vs 55.5 ± 2.3º, P = .03) and were more likely to have a phase SD ≥ 60º (53 % vs 35 %, P = .03). Fewer patients with potential SCD events (6 % vs 15 % of the controls, P = .08) had an MIBG heart/mediastinum uptake-ratio ≥1.6.

CONCLUSIONS

Among symptomatic HFrEF patients, LV mechanical dyssynchrony is independently associated with potential SCD events. Phase analysis may provide incremental prognostic information on top of current indicators of SCD risk in HFrEF.

Statins in heart failure--With preserved and reduced ejection fraction. An update

HMG-CoA reductase inhibitors or statins beyond their lipid lowering properties and mevalonate inhibition exert also their actions through a multiplicity of mechanisms. In heart failure (HF) the inhibition of isoprenoid intermediates and small GTPases, which control cellular function such as cell shape, secretion and proliferation, is of clinical significance. Statins share also the peroxisome proliferator-activated receptor pathway and inactivate extracellular-signal-regulated kinase phosphorylation suppressing inflammatory cascade. By down-regulating Rho/Rho kinase signaling pathways, statins increase the stability of eNOS mRNA and induce activation of eNOS through phosphatidylinositol 3-kinase/Akt/eNOS pathway restoring endothelial function. Statins change also myocardial action potential plateau by modulation of Kv1.5 and Kv4.3 channel activity and inhibit sympathetic nerve activity suppressing arrhythmogenesis. Less documented evidence proposes also that statins have anti-hypertrophic effects - through p21ras/mitogen activated protein kinase pathway - which modulate synthesis of matrix metalloproteinases and procollagen 1 expression affecting interstitial fibrosis and diastolic dysfunction. Clinical studies have partly confirmed the experimental findings and despite current guidelines new evidence supports the notion that statins can be beneficial in some cases of HF. In subjects with diastolic HF, moderately impaired systolic function, low b-type natriuretic peptide levels, exacerbated inflammatory response and mild interstitial fibrosis evidence supports that statins can favorably affect the outcome. Under the lights of this evidence in this review article we discuss the current knowledge on the mechanisms of statins' actions and we link current experimental and clinical data to further understand the possible impact of statins' treatment on HF syndrome.

An evaluation of the pharmacokinetics and pharmacodynamics of ivabradine for the treatment of heart failure

INTRODUCTION

Ivabradine is a new heart-rate-lowering drug; the aim of this review was to analyze its role in heart failure (HF).

AREAS COVERED

This systematic review on the role of ivabradine in HF is based on material searched and obtained through Pubmed and Medline up to September 2013.

EXPERT OPINION

Heart rate (HR) is a risk factor in patients with HF, and its reduction is considered an important goal of therapy. The BEAUTIFUL trial demonstrated the benefits of ivabradine on prognosis (only on ischemic endpoints) in patients with coronary artery disease (CAD) and left ventricular systolic dysfunction (LVSD) and HR ≥ 60 bpm. In the SHIFT trial, which enrolled patients with LVSD, HF and HR ≥ 70 bpm, ivabradine administration (on top of guideline-based therapy, including β-blockers [BB]) was associated with a reduction of cardiovascular death and hospitalizations for HF, but BB were underutilized. Further studies are needed to test the efficacy of ivabradine in CAD patients with high HR and to shed light on the comparison between ivabradine and a more aggressive therapy with higher doses of BB in HF patients.

Cost-effectiveness of a nurse-led education and psychosocial programme for patients with chronic heart failure and their partners

AIMS AND OBJECTIVES

This randomised controlled trial was conducted to estimate the cost-effectiveness of a nurse-led education and psychosocial support programme for patients with heart failure (HF) and their partners.

BACKGROUND

There are few studies evaluating cost-effectiveness of interventions among HF patient-partner dyads.

METHODS

Dyads randomised to the experimental group received nurse-led counselling, computer-based education and written materials aimed at developing problem-solving skills at two, six and 12 weeks after hospitalisation with HF exacerbation. The dyads in the control group received usual care. A cost-effectiveness analysis that included costs associated with staff time to deliver the intervention and travel costs was conducted at 12 months. Quality-adjusted life-year (QALY) weights for patients and partners were estimated by SF-6D.

RESULTS

A total of 155 dyads were included. The intervention cost was €223 per patient. Participants in both groups showed improvements in QALY weights after 12 months. However, no significant difference in QALY weights was found between the patients in the two groups, nor among their partners.

CONCLUSION

The intervention was not proven cost-effective, neither for patients nor for partners. The intervention, however, had trends (but not significant) effects on the patient-partner dyads, and by analysing the QALY gained from the dyad, a reasonable mean cost-effectiveness ratio was achieved.

RELEVANCE TO CLINICAL PRACTICE

The study shows trends of a cost-effective education and psychosocial care of HF patient-partner dyads.

Mechanisms of disease: is mitochondrial function altered in heart failure?

The human heart sustains an exceptional energy transfer rate, consuming more energy per gram weight than any other organ system. The healthy heart can rapidly adapt to changes in demand, while the failing heart cannot. Cardiac energy flux systems falter in the failing heart. The purpose of this review is to characterize the fundamental role of mitochondria in this energy transfer system and describe our local research on mitochondrial respiratory capacity in failing human hearts.

Heart failure in young adults: 20-year trends in hospitalization, aetiology, and case fatality in Sweden

AIMS

To describe trends in incidence and case fatality among younger (18-54 years) and older (55-84 years) Swedish patients with heart failure (HF).

METHODS AND RESULTS

Through linking the Swedish national hospital discharge and the cause-specific death registries, we identified patients aged 18-84 years that were discharged 1987-2006 with a diagnosis of HF. Age-specific mean incidence rates per 100 000 person-years were calculated in four 5-year periods. Kaplan-Meier survival curves were plotted up to 3 years. From 1987 to 2006, there were 443 995 HF hospitalizations among adults 18-84 years. Of these, 4660 (1.0%) and 13 507 (3.0%) occurred in people aged 18-44 and 45-54 years (31.6% women), respectively. From the first to the last 5-year period, HF incidence increased by 50 and 43%, among people aged 18-34 and 35-44 years, respectively. Among people ≥45 years, incidence peaked in the mid-1990s and then decreased. Heart failure in the presence of cardiomyopathy increased more than two-fold among all age groups. Case fatality decreased for all age groups until 2001, after which no further significant decrease <55 years was observed.

CONCLUSION

Increasing HF hospitalization in young adults in Sweden opposes the general trend seen in older patients, a finding which may reflect true epidemiological changes. Cardiomyopathy accounted for a substantial part of this increase. High case fatality and lack of further case fatality reduction after 2001 are causes for concern.

Patients with heart failure have an increased risk of incident cancer

OBJECTIVES

This study sought to evaluate the risk of cancer in patients with heart failure (HF) compared with community controls and to determine the impact of cancer post-HF on outcomes.

BACKGROUND

HF is associated with excess morbidity and mortality. Noncardiac causes of adverse outcomes in HF are increasingly recognized, but not fully characterized.

METHODS

In a case-control study, we compared the history of cancer among community subjects newly diagnosed with HF from 1979 to 2002 to age-, sex-, and date-matched community controls without HF (961 pairs). Individuals without cancer at the index date (596 pairs) were followed for cancer in a cohort design, and the survival of HF patients who developed cancer was assessed.

RESULTS

Before the index date, 22% of HF cases and 23% of controls had a history of cancer (odds ratio [OR]: 0.94; 95% confidence interval [CI]: 0.75 to 1.17). During 9,203 person-years of follow-up (7.7 ± 6.4 years), 244 new cancer cases were identified; HF patients had a 68% higher risk of developing cancer (hazard ratio [HR]: 1.68; 95% CI: 1.13 to 2.50) adjusted for body mass index, smoking, and comorbidities. The HRs were similar for men and women, with a trend toward a stronger association among subjects ≤75 years of age (p = 0.22) and during the most recent time period (p = 0.075). Among HF cases, incident cancer increased the risk of death (HR: 1.56; 95% CI: 1.22 to 1.99) adjusted for age, sex, index year, and comorbidities.

CONCLUSIONS

HF patients are at increased risk of cancer, which appears to have increased over time. Cancer increases mortality in HF, underscoring the importance of noncardiac morbidity and of cancer surveillance in the management of HF patients.

Patient preferences and willingness-to-pay for a home or clinic based program of chronic heart failure management: findings from the Which? trial

BACKGROUND

Beyond examining their overall cost-effectiveness and mechanisms of effect, it is important to understand patient preferences for the delivery of different modes of chronic heart failure management programs (CHF-MPs). We elicited patient preferences around the characteristics and willingness-to-pay (WTP) for a clinic or home-based CHF-MP.

METHODOLOGY/PRINCIPAL FINDINGS

A Discrete Choice Experiment was completed by a sub-set of patients (n = 91) enrolled in the WHICH? trial comparing home versus clinic-based CHF-MP. Participants provided 5 choices between hypothetical clinic and home-based programs varying by frequency of nurse consultations, nurse continuity, patient costs, and availability of telephone or education support. Participants (aged 71±13 yrs, 72.5% male, 25.3% NYHA class III/IV) displayed two distinct preference classes. A latent class model of the choice data indicated 56% of participants preferred clinic delivery, access to group CHF education classes, and lower cost programs (p<0.05). The remainder preferred home-based CHF-MPs, monthly rather than weekly visits, and access to a phone advice service (p<0.05). Continuity of nurse contact was consistently important. No significant association was observed between program preference and participant allocation in the parent trial. WTP was estimated from the model and a dichotomous bidding technique. For those preferring clinic, estimated WTP was ≈AU$9-20 per visit; however for those preferring home-based programs, WTP varied widely (AU$15-105).

CONCLUSIONS/SIGNIFICANCE

Patient preferences for CHF-MPs were dichotomised between a home-based model which is more likely to suit older patients, those who live alone, and those with a lower household income; and a clinic-based model which is more likely to suit those who are more socially active and wealthier. To optimise the delivery of CHF-MPs, health care services should consider their patients' preferences when designing CHF-MPs.

Effects of extreme temperatures on years of life lost for cardiovascular deaths: a time series study in Brisbane, Australia

BACKGROUND

Extreme temperatures are associated with cardiovascular disease (CVD) deaths. Previous studies have investigated the relative CVD mortality risk of temperature, but this risk is heavily influenced by deaths in frail elderly people. To better estimate the burden of extreme temperatures, we estimated their effects on years of life lost due to CVD.

METHODS AND RESULTS

The data were daily observations on weather and CVD mortality for Brisbane, Australia, between 1996 and 2004. We estimated the association between daily mean temperature and years of life lost due to CVD, after adjusting for trend, season, day of the week, and humidity. To examine the nonlinear and delayed effects of temperature, a distributed lag nonlinear model was used. The model's residuals were examined to investigate whether there were any added effects due to cold spells and heat waves. The exposure-response curve between temperature and years of life lost was U-shaped, with the lowest years of life lost at 24°C. The curve had a sharper rise at extremes of heat than of cold. The effect of cold peaked 2 days after exposure, whereas the greatest effect of heat occurred on the day of exposure. There were significantly added effects of heat waves on years of life lost.

CONCLUSIONS

Increased years of life lost due to CVD are associated with both cold and hot temperatures. Research on specific interventions is needed to reduce temperature-related years of life lost from CVD deaths.

Nurse-led care of heart failure: will it work in remote settings?

This paper reviews the role of predominantly nurse-led, multidisciplinary, chronic heart failure management programs as part of the gold-standard management of patients discharged from hospital with this syndrome. It discusses the various options for applying these evidence-based programs and how they apply to the management of those living in rural/remote Australia. Specifically, it describes the challenges of applying CHF management in remote settings and how face-to-face, family based programs of care might be particularly effective from an Indigenous perspective. Finally, it describes ongoing research to determine the best approach to CHF management in remote settings.

Evaluation of prevalent and incident ovarian cancer co-morbidity

BACKGROUND

The peak in incidence of ovarian cancer occurs around 65 years and concurrent increasing risk by age for a number of diseases strongly influence treatment and prognosis. The aim was to explore prevalence and incidence of co-morbidity in ovarian cancer patients compared with the general population.

METHODS

The study population was patients with ovarian cancer in Sweden 1993-2006 (n=11 139) and five controls per case (n=55 687). Co-morbidity from 1987 to 2006 was obtained from the Swedish Patient Register. Prevalent data were analysed with logistic regression and incident data with Cox proportional hazards models.

RESULTS

Women developing ovarian cancer did not have higher overall morbidity than other women earlier than 3 months preceding cancer diagnosis. However, at time of diagnosis 11 of 13 prevalent diagnosis groups were more common among ovarian cancer patients compared with controls. The incidence of many common diagnoses was increased several years following the ovarian cancer and the most common diagnoses during the follow-up period were thromboembolism, haematologic and gastrointestinal complications.

CONCLUSION

Women developing ovarian cancer do not have higher overall morbidity the years preceding cancer diagnosis. The incidence of many common diagnoses was increased several years following the ovarian cancer. It is crucial to consider time between co-morbidity and cancer diagnosis to understand and interpret associations.

Screening for mild cognitive impairment in patients with heart failure: Montreal cognitive assessment versus mini mental state exam

BACKGROUND

Cognitive impairments occur frequently in patients with chronic heart failure (CHF), resulting in worse health outcomes than expected. These impairments can remain undetected unless specifically screened. There are limited sensitive screening measures available in nursing practice to identify mild cognitive impairment (MCI).

AIM

To compare the Montreal Cognitive Assessment (MoCA) with the Mini Mental State Exam (MMSE) in screening for MCI in CHF patients.

METHODS

The MMSE and MoCA were administered to 93 hospitalized CHF patients (70±11 years), without a history of neurocognitive problems. Patients with low MoCA scores (<26) were compared to those with low MMSE scores (<27). Two different parameters were examined between the MoCA and the MMSE: level of MCI agreement (Kappa coefficient) and task errors on assessed cognitive domains (χ2 test).

RESULTS

Statistically more patients had low MoCA scores compared with low MMSE scores (66 vs. 30, p=0.02). The MoCA classified 38 (41%) patients as cognitively impaired that were not classified by the MMSE. A significantly low level of agreement was found (κ=0.25, p=0.001) between the MMSE and MoCA in identifying patients with scores suggestive of MCI. More task errors were observed on the MoCA cognitive domains compared with the MMSE cognitive domains. In 68% of patients with low cognitive scores, visuospatial task errors were observed on tasks from the MoCA compared with 22% on a similar task of the MMSE.

CONCLUSION

The MoCA, a screening tool for MCI, identified subtle but potentially clinically relevant cognitive dysfunctions with greater frequency than MMSE.

Circulation: Heart Failure's Editors' Picks: Most Important Papers in Epidemiology and Outcomes

The following are highlights from the new series, Circulation: Heart Failure Topic Review. This series will summarize the most important manuscripts, as selected by the editors, which have published in the Circulation portfolio. The objective of this new series is to provide our readership with a timely and comprehensive selection of important papers that are relevant to the heart failure audience, covering a variety of areas within the heart failure field. The studies included in this article represent the most noteworthy research in the areas of epidemiology and outcomes.

Trends in long-term cardiovascular mortality and morbidity in men and women with heart failure of ischemic versus non-ischemic aetiology in Western Australia between 1990 and 2005

BACKGROUND

It is uncertain if improvements in long-term cardiovascular (CV) mortality have occurred in both men and women with ischemic and non-ischemic forms of heart failure (HF).

METHODS

The Western Australia Hospital Morbidity Database was used to identify all index (first-ever) hospitalizations for HF between 1990 and 2005. Patients were followed until death attributed to cardiovascular causes or censored on December 31, 2006 to determine 5-year survival. Cox proportional hazards models were used to compare the adjusted mortality hazard ratio (HR) during the study follow-up (4-year periods).

RESULTS

A total of 21,507 patients (mean age 73.9 years, 49.1% women) were identified. Women were significantly older than men, and less likely to have ischemic HF (38.8% versus 46.1%). Over the period, age-standardized incidence of first HF hospitalization declined but with the least decline in women with non-ischemic HF (-13.3%) compared to other subgroups. Risk-adjusted 5-year CV mortality declined over the study period, with HR 0.64 (95% CI 0.60-0.68) for patients admitted in 1998-2001 compared to 1990-1993, with significant improvement in both forms of HF, and in both sexes and across age groups. However, overall total HF hospitalizations increased (+26.7%) over the period, particularly for non-ischemic HF (+43.7%), of which elderly women formed the predominant group.

CONCLUSIONS

Risk-adjusted long-term survival improved similarly in men and women, including the elderly, with ischemic and non-ischemic forms of HF during 1990-2005 in Western Australia. However, there was a growing burden of HF hospitalizations particularly for HF of non-ischemic aetiology.

Optimising management of hypertension in primary care: the Valsartan Intensified Primary Care Reduction of Blood Pressure (Viper-Bp) study

BACKGROUND

The Valstartan Intensified Primary CarE Reduction of Blood Pressure Study (VIPER-BP) Study is an open-label, randomised controlled trial comparing usual primary care management with an intensive BP management strategy using three forms of valsartan-based therapy (mono-therapy, thiazide diuretic or calcium channel blocker combinations) to achieve individualised BP control.

METHODS

To identify the features of General Practitioner (GP) management of hypertension in Australia, we analyse the response to a case scenario-based survey of 500 GPs. We subsequently recruited a national cohort of GP Investigators to enrol up to 2500 patients into the VIPER-BP Study.

RESULTS

GP responses clearly demonstrated that, compared to the VIPER-BP intervention, a heterogeneous approach to the primary care management of hypertension persists in Australia. By November 2010, 2157 hypertensive patients from 272 actively recruiting GP Investigators were enrolled into the study. Of these, 1965 (91%) patients were entered into a standardised "run-in" phase of 28 days of valsartan 80 mg/day. Subsequently, 1285 patients were randomised to usual care (n=435) or the VIPER-BP intervention (n=850). There was a predominance of males (62%), whilst 55% had pre-existing diabetes or cardiovascular disease and 63% had been previously treated for hypertension. Mean systolic and diastolic BP on randomisation for men and women, respectively, was 148 ± 15/88 ± 11 and 148 ± 18/87 ± 10 mm Hg.

CONCLUSIONS

In contrast to typical primary care management of hypertension, VIPER-BP combines more intensive and aggressive therapies with structured management to more rapidly attain and sustain individualised BP targets in hypertensive patients.