201
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Pascual-Figal DA, Redondo B, Caro C, Manzano S, Garrido IP, Ruipérez JA, Valdés M. Comparison of late mortality in hospitalized patients >70 years of age with systolic heart failure receiving beta blockers versus those not receiving beta blockers. Am J Cardiol 2008; 102:1711-7. [PMID: 19064029 DOI: 10.1016/j.amjcard.2008.07.059] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2008] [Revised: 07/25/2008] [Accepted: 07/25/2008] [Indexed: 10/21/2022]
Abstract
Beta blockers are underprescribed to elderly patients with systolic heart failure (HF). We studied whether the prescription of a beta blocker is associated with a survival benefit in a nonselected population of patients >70 years of age hospitalized with acute HF and systolic dysfunction. We studied 272 consecutive patients >70 years (median 77.0, interquartile range 73.4 to 81.1) hospitalized with acute HF (left ventricular ejection fraction 34 +/- 8%) during a 2-year period. At discharge, beta-blocker therapy was prescribed in 139 patients (51.1%). A propensity score for the likelihood of receiving beta-blocker therapy was developed and showed a good performance (c-statistic = 0.825 and Hosmer-Lemeshow p = 0.820). After discharge, 120 patients (44.1%) died during the follow-up (median 31 months, interquartile range 12 to 46). Cox regression analysis showed a lower risk of death associated with beta-blocker prescription (p <0.001, hazard ratio [HR] 0.450, 95% confidence interval [CI] 0.310 to 0.655), which persisted after risk adjusting for the propensity score (HR 0.521, 95% CI 0.325 to 0.836, p = 0.007). In a propensity-matched cohort of 130 patients, there was a significantly lower mortality in patients receiving beta blockers (log rank 0.009, HR 0.415, 95% CI 0.234 to 0.734, p = 0.003). Risk reduction associated with beta blockade was observed with both high doses (HR 0.472, 95% CI 0.300 to 0.742, p = 0.001) and low doses (HR 0.425, 95% CI 0.254 to 0.711, p = 0.001). In conclusion, beta-blocker prescription at discharge in a nonselected population >70 years of age hospitalized with systolic HF is associated with a significantly lower risk of death even at low doses. This benefit remains consistent after adjustment for potential confounders.
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202
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Goode KM, Clark AL, Bristow JA, Sykes KB, Cleland JG. Screening for left ventricular systolic dysfunction in high-risk patients in primary-care: A cost-benefit analysis. Eur J Heart Fail 2008; 9:1186-95. [DOI: 10.1016/j.ejheart.2007.10.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2007] [Revised: 09/24/2007] [Accepted: 10/11/2007] [Indexed: 11/29/2022] Open
Affiliation(s)
- Kevin M. Goode
- Department of Cardiology; Castle Hill Hospital; Kingston-upon-Hull United Kingdom
| | - Andrew L. Clark
- Department of Cardiology; Castle Hill Hospital; Kingston-upon-Hull United Kingdom
| | - Janet A. Bristow
- Department of Cardiology; Castle Hill Hospital; Kingston-upon-Hull United Kingdom
| | - Kim B. Sykes
- Department of Cardiology; Castle Hill Hospital; Kingston-upon-Hull United Kingdom
| | - John G.F. Cleland
- Department of Cardiology; Castle Hill Hospital; Kingston-upon-Hull United Kingdom
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203
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Störk S, Hense HW, Zentgraf C, Uebelacker I, Jahns R, Ertl G, Angermann CE. Pharmacotherapy according to treatment guidelines is associated with lower mortality in a community-based sample of patients with chronic heart failure A prospective cohort study. Eur J Heart Fail 2008; 10:1236-45. [DOI: 10.1016/j.ejheart.2008.09.008] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2008] [Revised: 07/03/2008] [Accepted: 09/22/2008] [Indexed: 11/29/2022] Open
Affiliation(s)
- Stefan Störk
- Department of Internal Medicine I/Center for Cardiovascular Medicine; University of Würzburg; Klinikstrasse 6-8 D-97070 Würzburg Germany
| | - Hans Werner Hense
- Institute of Epidemiology and Social Medicine, University of Münster; Domagkstr. 3 D-48129 Münster Germany
| | - Claudia Zentgraf
- Department of Internal Medicine I/Center for Cardiovascular Medicine; University of Würzburg; Klinikstrasse 6-8 D-97070 Würzburg Germany
| | - Iris Uebelacker
- Department of Internal Medicine I/Center for Cardiovascular Medicine; University of Würzburg; Klinikstrasse 6-8 D-97070 Würzburg Germany
| | - Roland Jahns
- Department of Internal Medicine I/Center for Cardiovascular Medicine; University of Würzburg; Klinikstrasse 6-8 D-97070 Würzburg Germany
| | - Georg Ertl
- Department of Internal Medicine I/Center for Cardiovascular Medicine; University of Würzburg; Klinikstrasse 6-8 D-97070 Würzburg Germany
| | - Christiane E. Angermann
- Department of Internal Medicine I/Center for Cardiovascular Medicine; University of Würzburg; Klinikstrasse 6-8 D-97070 Würzburg Germany
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204
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Cohen-Solal A, McMurray JJV, Swedberg K, Pfeffer MA, Puu M, Solomon SD, Michelson EL, Yusuf S, Granger CB. Benefits and safety of candesartan treatment in heart failure are independent of age: insights from the Candesartan in Heart failure--Assessment of Reduction in Mortality and morbidity programme. Eur Heart J 2008; 29:3022-8. [PMID: 18987098 DOI: 10.1093/eurheartj/ehn476] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
AIMS Ageing may affect drug efficacy and safety in patients with heart failure (HF). The Candesartan in Heart failure-Assessment of Reduction in Mortality and morbidity (CHARM) programme offered an opportunity to study the relationship between increasing age and the efficacy and safety of treatment in an uniquely broad spectrum of patients with symptomatic HF and either reduced or preserved left ventricular ejection fraction. METHODS AND RESULTS A total of 7599 patients in NYHA Class II-IV HF were randomized to candesartan (target dose 32 mg once daily, mean dose 24 mg) or placebo, including 3169 patients age >70 years. Mean follow-up was 37.7 months. The proportional hazards model was used to estimate the treatment effect on efficacy and safety within five age groups: <50 years (n = 605) (8% of all study patients), 50-59 years (n = 1474) (19%), 60-69 years (n = 2351) (31%), 70-79 years (n = 2474) (33%), and > or =80 years (n = 695) (9%). The risk of cardiovascular (CV) death or HF hospitalization (primary outcome) increased from 24% in the lowest age group to 46% in the highest age group (and mortality from 13 to 42%). The relative reduction in risk of the primary outcome with candesartan (15% in the overall study population) was similar irrespective of age. Consequently, the absolute benefit was greater with advancing age (3.8 patients avoided a primary outcome per 100 patients treated in the lowest age group compared with 6.8 in the highest). Adverse events leading to drug discontinuation were more frequent in the candesartan group: placebo/candesartan risk (%), lowest compared with highest age category: hyperkalemia (0.0/1.6 vs. 0.6/2.7), increased serum creatinine (1.0/3.9 vs. 6.1/5.4) and hypotension (1.7/2.0 vs. 2.8/5.7). CONCLUSION Older patients were at a greater absolute risk of adverse CV mortality and morbidity outcomes but derived a similar relative risk reduction and, therefore, a greater absolute benefit from treatment with candesartan, despite receiving a somewhat lower mean daily dose of candesartan. Adverse effects were more common with candesartan than with placebo, although the relative risk of adverse effects was similar across age groups. The benefit to risk ratio for candesartan was thus favourable across all age groups.
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205
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Tabet JY, Meurin P, Beauvais F, Weber H, Renaud N, Thabut G, Cohen-Solal A, Logeart D, Driss AB. Absence of Exercise Capacity Improvement After Exercise Training Program. Circ Heart Fail 2008; 1:220-6. [DOI: 10.1161/circheartfailure.108.775460] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
Exercise training is established as adjuvant therapy for chronic heart failure, but the prognostic value of improvement in exercise capacity after exercise training has never been evaluated.
Methods and Results—
In this prospective bicentric study, all chronic heart failure patients with left ventricular ejection fraction <45% who underwent an exercise training program in a cardiac rehabilitation center between January 2004 and September 2006 were consecutively included. Improvement in exercise capacity was assessed by change in peak oxygen consumption (δPV
o
2
) and in PV
o
2
expressed as a percentage of predicted PV
o
2
(δ%PPV
o
2
) measured before and after the training program. We included 155 patients (54�12 years old, male 81%, left ventricular ejection fraction=29.5�7.1%). Patients underwent 20 (10–30) training sessions. PV
o
2
and %PPV
o
2
were significantly increased after the training program (14% and 13%, respectively,
P
<0.001 for both). After 16�6 months follow-up, 27 patients had a cardiac event (death [n=12], cardiac transplantation [n=5], hospitalization for acute heart failure [n=10]). Univariate analysis revealed that among 17 significant predictors of cardiac events, the 2 more powerful ones were level of B-type natriuretic peptide at baseline (
P
<0.0001) and improvement in exercise capacity as assessed by δPV
o
2
and δ%PPV
o
2
(
P
<0.0001). Multivariate analysis revealed B-type natriuretic peptide level and δ%PPV
o
2
as only independent predictive factors of outcome (
P
=0.01). The risk ratio of cardiac events for nonresponse versus response to the training program (defined as median δ%PPV
o
2
<6%) was 8.2 (
P
=0.0006).
Conclusions—
Among patients with chronic heart failure, the lack of improvement in exercise capacity after an exercise training program has strong prognostic value for adverse cardiac events independent of classical predictive factors such as left ventricular ejection fraction, New York Heart Association class, and B-type natriuretic peptide level.
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Affiliation(s)
- Jean-Yves Tabet
- From the Les Grands Près, Centre de Réadaptation Cardiaque de la Brie (CRCB), Villeneuve-Saint-Denis, France (J.-Y.T., P.M., H.W., N.R., A.B.D.); Service de Cardiologie, Hôpital Lariboisiere, Faculté de Médecine Paris Diderot, INSERM 689, Paris, France (J.-Y.T., F.B., A.C.S., D.L.); and Service de Pneumologie, Hôpital Bichat, Faculté de Médecine Paris Diderot, Paris, France (G.T.)
| | - Philippe Meurin
- From the Les Grands Près, Centre de Réadaptation Cardiaque de la Brie (CRCB), Villeneuve-Saint-Denis, France (J.-Y.T., P.M., H.W., N.R., A.B.D.); Service de Cardiologie, Hôpital Lariboisiere, Faculté de Médecine Paris Diderot, INSERM 689, Paris, France (J.-Y.T., F.B., A.C.S., D.L.); and Service de Pneumologie, Hôpital Bichat, Faculté de Médecine Paris Diderot, Paris, France (G.T.)
| | - Florence Beauvais
- From the Les Grands Près, Centre de Réadaptation Cardiaque de la Brie (CRCB), Villeneuve-Saint-Denis, France (J.-Y.T., P.M., H.W., N.R., A.B.D.); Service de Cardiologie, Hôpital Lariboisiere, Faculté de Médecine Paris Diderot, INSERM 689, Paris, France (J.-Y.T., F.B., A.C.S., D.L.); and Service de Pneumologie, Hôpital Bichat, Faculté de Médecine Paris Diderot, Paris, France (G.T.)
| | - Hélène Weber
- From the Les Grands Près, Centre de Réadaptation Cardiaque de la Brie (CRCB), Villeneuve-Saint-Denis, France (J.-Y.T., P.M., H.W., N.R., A.B.D.); Service de Cardiologie, Hôpital Lariboisiere, Faculté de Médecine Paris Diderot, INSERM 689, Paris, France (J.-Y.T., F.B., A.C.S., D.L.); and Service de Pneumologie, Hôpital Bichat, Faculté de Médecine Paris Diderot, Paris, France (G.T.)
| | - Nathalie Renaud
- From the Les Grands Près, Centre de Réadaptation Cardiaque de la Brie (CRCB), Villeneuve-Saint-Denis, France (J.-Y.T., P.M., H.W., N.R., A.B.D.); Service de Cardiologie, Hôpital Lariboisiere, Faculté de Médecine Paris Diderot, INSERM 689, Paris, France (J.-Y.T., F.B., A.C.S., D.L.); and Service de Pneumologie, Hôpital Bichat, Faculté de Médecine Paris Diderot, Paris, France (G.T.)
| | - Gabriel Thabut
- From the Les Grands Près, Centre de Réadaptation Cardiaque de la Brie (CRCB), Villeneuve-Saint-Denis, France (J.-Y.T., P.M., H.W., N.R., A.B.D.); Service de Cardiologie, Hôpital Lariboisiere, Faculté de Médecine Paris Diderot, INSERM 689, Paris, France (J.-Y.T., F.B., A.C.S., D.L.); and Service de Pneumologie, Hôpital Bichat, Faculté de Médecine Paris Diderot, Paris, France (G.T.)
| | - Alain Cohen-Solal
- From the Les Grands Près, Centre de Réadaptation Cardiaque de la Brie (CRCB), Villeneuve-Saint-Denis, France (J.-Y.T., P.M., H.W., N.R., A.B.D.); Service de Cardiologie, Hôpital Lariboisiere, Faculté de Médecine Paris Diderot, INSERM 689, Paris, France (J.-Y.T., F.B., A.C.S., D.L.); and Service de Pneumologie, Hôpital Bichat, Faculté de Médecine Paris Diderot, Paris, France (G.T.)
| | - Damien Logeart
- From the Les Grands Près, Centre de Réadaptation Cardiaque de la Brie (CRCB), Villeneuve-Saint-Denis, France (J.-Y.T., P.M., H.W., N.R., A.B.D.); Service de Cardiologie, Hôpital Lariboisiere, Faculté de Médecine Paris Diderot, INSERM 689, Paris, France (J.-Y.T., F.B., A.C.S., D.L.); and Service de Pneumologie, Hôpital Bichat, Faculté de Médecine Paris Diderot, Paris, France (G.T.)
| | - Ahmed Ben Driss
- From the Les Grands Près, Centre de Réadaptation Cardiaque de la Brie (CRCB), Villeneuve-Saint-Denis, France (J.-Y.T., P.M., H.W., N.R., A.B.D.); Service de Cardiologie, Hôpital Lariboisiere, Faculté de Médecine Paris Diderot, INSERM 689, Paris, France (J.-Y.T., F.B., A.C.S., D.L.); and Service de Pneumologie, Hôpital Bichat, Faculté de Médecine Paris Diderot, Paris, France (G.T.)
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206
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Ray P, Delerme S, Jourdain P, Chenevier-Gobeaux C. Differential diagnosis of acute dyspnea: the value of B natriuretic peptides in the emergency department. QJM 2008; 101:831-43. [PMID: 18664534 DOI: 10.1093/qjmed/hcn080] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
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.
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Affiliation(s)
- P Ray
- Service d'Accueil des Urgences, Groupe Hospitalier Pitié-Salpêtrière, Paris, France.
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207
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Miles A, Loughlin M, Polychronis A. Evidence-based healthcare, clinical knowledge and the rise of personalised medicine. J Eval Clin Pract 2008; 14:621-49. [PMID: 19018885 DOI: 10.1111/j.1365-2753.2008.01094.x] [Citation(s) in RCA: 75] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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208
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Peters-Klimm F, Müller-Tasch T, Remppis A, Szecsenyi J, Schellberg D. Improved guideline adherence to pharmacotherapy of chronic systolic heart failure in general practice--results from a cluster-randomized controlled trial of implementation of a clinical practice guideline. J Eval Clin Pract 2008; 14:823-9. [PMID: 19018915 DOI: 10.1111/j.1365-2753.2008.01060.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
RATIONALE AND AIMS Clinical practice guidelines (CPG) reflect the evidence of effective pharmacotherapy of chronic (systolic) heart failure (CHF) which needs to be implemented. This study aimed to evaluate the effect of a new, multifaceted intervention (educational train-the-trainer course plus pharmacotherapy feedback = TTT) compared with standard education on guideline adherence (GA) in general practice. METHOD Thirty-seven participating general practitioners (GPs) were randomized (18 vs. 19) and included 168 patients with ascertained symptomatic CHF [New York Heart Association (NYHA) II-IV]. Groups received CPG, the TTT intervention consisted of four interactive educational meetings and a pharmacotherapy feedback, while the control group received a usual lecture (Standard). Outcome measure was GA assessed by prescription rates and target dosing of angiotensin converting enzyme (ACE) inhibitors (ACE-I) or angiotensin receptor blockers (ARB), beta-blockers (BB) and aldosterone antagonists (AA) at baseline and 7-month follow-up. Group comparisons at follow-up were adjusted to GA, sex, age and NYHA stage at baseline. RESULTS Prescription rates at baseline (n = 168) were high (ACE-I/ARB 90, BB 79 and AA 29%) in both groups. At follow up (n = 146), TTT improved compared with Standard regarding AA (43% vs. 23%, P = 0.04) and the rates of reached target doses of ACE-I/ARB (28% vs. 15%, P = 0.04). TTT group achieved significantly higher mean percentages of daily target dose (52% vs. 42%, mean difference 10.3%, 95% CI 0.84-19.8, P = 0.03). CONCLUSION Despite of pre-existing high GA in both groups and an active control group, the multifaceted intervention was effective in quality of care measured by GA. Further research is needed on the choice of interventions in different provider populations.
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Affiliation(s)
- Frank Peters-Klimm
- Department of Genral Practice and Health Services Research, University Hospital Heidelberg, Germany.
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209
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Peterson ED, Albert NM, Amin A, Patterson JH, Fonarow GC. Implementing critical pathways and a multidisciplinary team approach to cardiovascular disease management. Am J Cardiol 2008; 102:47G-56G. [PMID: 18722192 DOI: 10.1016/j.amjcard.2008.06.011] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
According to several medical registries, there is a need to improve the care of post-myocardial infarction (MI) patients, especially those with left ventricular dysfunction (LVD) and heart failure. This can potentially be achieved by implementing disease management programs, which include critical pathways, patient education, and multidisciplinary hospital teams. Currently, algorithms for critical pathways, including discharge processes, are lacking for post-MI LVD patients. Such schemes can increase the use of evidence-based medicines proved to reduce mortality. Educational programs are aimed at increasing patients' awareness of their condition, promoting medication compliance, and encouraging the adoption of healthy behaviors; such programs have been shown to be effective in improving outcomes of post-MI LVD patients. Reductions in all-cause hospitalizations and medical costs as well as improved survival rates have been observed when a multidisciplinary team (a nurse, a pharmacist, and a hospitalist) is engaged in patient care. In addition, the use of the "pay for performance" method, which can be advantageous for patients, physicians, and hospitals, may potentially improve the care of post-MI patients with LVD.
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210
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Implementation of Beta-Blockade in Elderly Heart Failure Patients: Role of the Nurse Specialist. Eur J Cardiovasc Nurs 2008; 7:196-203. [DOI: 10.1016/j.ejcnurse.2007.09.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2006] [Revised: 09/26/2007] [Accepted: 09/27/2007] [Indexed: 12/22/2022]
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211
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“Diastolic” heart failure, overlooked systolic dysfunction, altered ventriculo-arterial coupling or limitation of cardiac reserve? Int J Cardiol 2008; 128:299-303. [DOI: 10.1016/j.ijcard.2008.02.021] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2007] [Revised: 12/14/2007] [Accepted: 02/09/2008] [Indexed: 11/24/2022]
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212
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Abstract
Diastolic heart failure (DHF) is a major cardiovascular disorder with poor prognosis; however, its molecular mechanism still remains to be fully elucidated. We have previously demonstrated the important roles of Rho-kinase pathway in the molecular mechanisms of cardiovascular fibrosis/hypertrophy and oxidative stress, but not examined in the development of heart failure. Therefore, we examined in this study whether Rho-kinase pathway is also involved in the pathogenesis of DHF in Dahl salt-sensitive rats, an established animal model of DHF. They were maintained with or without fasudil, a Rho-kinase inhibitor (30 or 100 mg/kg/day, PO) for 10 weeks. Untreated DHF group exhibited overt heart failure associated with diastolic dysfunction but with preserved systolic function, characterized by increased myocardial stiffness, cardiomyocyte hypertrophy, and enhanced cardiac fibrosis and superoxide production. Fasudil treatment significantly ameliorated those DHF-related myocardial changes. Western blot analysis showed that cardiac Rho-kinase activity was significantly increased in the untreated DHF group and was dose-dependently inhibited by fasudil. Importantly, there was a significant correlation between the extent of myocardial stiffness and that of cardiac Rho-kinase activity. These results indicate that Rho-kinase pathway plays an important role in the pathogenesis of DHF and thus could be an important therapeutic target for the disorder.
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213
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Fonarow GC, Abraham WT, Albert NM, Stough WG, Gheorghiade M, Greenberg BH, O'Connor CM, Sun JL, Yancy CW, Young JB. Influence of Beta-Blocker Continuation or Withdrawal on Outcomes in Patients Hospitalized With Heart Failure. J Am Coll Cardiol 2008; 52:190-9. [DOI: 10.1016/j.jacc.2008.03.048] [Citation(s) in RCA: 177] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2007] [Revised: 03/10/2008] [Accepted: 03/12/2008] [Indexed: 11/25/2022]
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214
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Fonarow GC, Yancy CW, Albert NM, Curtis AB, Stough WG, Gheorghiade M, Heywood JT, McBride ML, Mehra MR, O'Connor CM, Reynolds D, Walsh MN. Heart Failure Care in the Outpatient Cardiology Practice Setting. Circ Heart Fail 2008; 1:98-106. [DOI: 10.1161/circheartfailure.108.772228] [Citation(s) in RCA: 151] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
Few data exist regarding contemporary care patterns for heart failure (HF) in the outpatient setting. IMPROVE HF is a prospective cohort study designed to characterize current management of patients with chronic HF and ejection fraction ≤35% in a national registry of 167 US outpatient cardiology practices.
Methods and Results—
Baseline patient characteristics and data on care of 15381 patients with diagnosed HF or prior myocardial infarction and left ventricular dysfunction were collected by chart abstraction. To quantify use of therapies, 7 individual metrics (use of angiotensin-converting enzyme inhibitor/angiotensin receptor blocker, β-blocker, aldosterone antagonist, anticoagulation, implantable cardioverter defibrillator, cardiac resynchronization therapy, and HF education) and composite metrics were assessed. Care metrics include only patients documented to be eligible and without contraindications or intolerance. Among practices, 69% were nonteaching. Patients were 71% male, with a median age of 70 years, and a median ejection fraction of 25%. Use of angiotensin-converting enzyme inhibitor/angiotensin receptor blocker (80%) and β-blocker (86%) was relatively high in eligible patients in the outpatient cardiology setting; other metrics, such as aldosterone antagonist (36%), device therapy (implantable cardioverter defibrillator/cardiac resynchronization therapy with defibrillator, 51%; cardiac resynchronization therapy, 39%), and education (61%), showed lower rates of use. A median 27% of patients received all HF therapies for which they were potentially eligible on the basis of chart documentation. Use of guideline-recommended therapies by practices varied widely.
Conclusions—
These data are among the first to assess treatment in the outpatient setting since the release of the latest national HF guidelines and to demonstrate substantial variation among cardiology practices in the documented therapies provided to HF patients.
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Affiliation(s)
- Gregg C. Fonarow
- From the Department of Medicine (G.C.F.), Ahmanson-UCLA Cardiomyopathy Center, UCLA Medical Center, Los Angeles, Calif, Baylor Heart and Vascular Institute (C.W.Y.), Baylor University Medical Center, Dallas, Tex, Nursing Institute and George M. and Linda H. Kaufman Center for Heart Failure (N.M.A.), Cleveland Clinic Foundation, Cleveland, Ohio, Division of Cardiology (A.B.C.), University of South Florida College of Medicine, Tampa, Fla, Department of Clinical Research (W.G.S.), Campbell University
| | - Clyde W. Yancy
- From the Department of Medicine (G.C.F.), Ahmanson-UCLA Cardiomyopathy Center, UCLA Medical Center, Los Angeles, Calif, Baylor Heart and Vascular Institute (C.W.Y.), Baylor University Medical Center, Dallas, Tex, Nursing Institute and George M. and Linda H. Kaufman Center for Heart Failure (N.M.A.), Cleveland Clinic Foundation, Cleveland, Ohio, Division of Cardiology (A.B.C.), University of South Florida College of Medicine, Tampa, Fla, Department of Clinical Research (W.G.S.), Campbell University
| | - Nancy M. Albert
- From the Department of Medicine (G.C.F.), Ahmanson-UCLA Cardiomyopathy Center, UCLA Medical Center, Los Angeles, Calif, Baylor Heart and Vascular Institute (C.W.Y.), Baylor University Medical Center, Dallas, Tex, Nursing Institute and George M. and Linda H. Kaufman Center for Heart Failure (N.M.A.), Cleveland Clinic Foundation, Cleveland, Ohio, Division of Cardiology (A.B.C.), University of South Florida College of Medicine, Tampa, Fla, Department of Clinical Research (W.G.S.), Campbell University
| | - Anne B. Curtis
- From the Department of Medicine (G.C.F.), Ahmanson-UCLA Cardiomyopathy Center, UCLA Medical Center, Los Angeles, Calif, Baylor Heart and Vascular Institute (C.W.Y.), Baylor University Medical Center, Dallas, Tex, Nursing Institute and George M. and Linda H. Kaufman Center for Heart Failure (N.M.A.), Cleveland Clinic Foundation, Cleveland, Ohio, Division of Cardiology (A.B.C.), University of South Florida College of Medicine, Tampa, Fla, Department of Clinical Research (W.G.S.), Campbell University
| | - Wendy Gattis Stough
- From the Department of Medicine (G.C.F.), Ahmanson-UCLA Cardiomyopathy Center, UCLA Medical Center, Los Angeles, Calif, Baylor Heart and Vascular Institute (C.W.Y.), Baylor University Medical Center, Dallas, Tex, Nursing Institute and George M. and Linda H. Kaufman Center for Heart Failure (N.M.A.), Cleveland Clinic Foundation, Cleveland, Ohio, Division of Cardiology (A.B.C.), University of South Florida College of Medicine, Tampa, Fla, Department of Clinical Research (W.G.S.), Campbell University
| | - Mihai Gheorghiade
- From the Department of Medicine (G.C.F.), Ahmanson-UCLA Cardiomyopathy Center, UCLA Medical Center, Los Angeles, Calif, Baylor Heart and Vascular Institute (C.W.Y.), Baylor University Medical Center, Dallas, Tex, Nursing Institute and George M. and Linda H. Kaufman Center for Heart Failure (N.M.A.), Cleveland Clinic Foundation, Cleveland, Ohio, Division of Cardiology (A.B.C.), University of South Florida College of Medicine, Tampa, Fla, Department of Clinical Research (W.G.S.), Campbell University
| | - J. Thomas Heywood
- From the Department of Medicine (G.C.F.), Ahmanson-UCLA Cardiomyopathy Center, UCLA Medical Center, Los Angeles, Calif, Baylor Heart and Vascular Institute (C.W.Y.), Baylor University Medical Center, Dallas, Tex, Nursing Institute and George M. and Linda H. Kaufman Center for Heart Failure (N.M.A.), Cleveland Clinic Foundation, Cleveland, Ohio, Division of Cardiology (A.B.C.), University of South Florida College of Medicine, Tampa, Fla, Department of Clinical Research (W.G.S.), Campbell University
| | - Mark L. McBride
- From the Department of Medicine (G.C.F.), Ahmanson-UCLA Cardiomyopathy Center, UCLA Medical Center, Los Angeles, Calif, Baylor Heart and Vascular Institute (C.W.Y.), Baylor University Medical Center, Dallas, Tex, Nursing Institute and George M. and Linda H. Kaufman Center for Heart Failure (N.M.A.), Cleveland Clinic Foundation, Cleveland, Ohio, Division of Cardiology (A.B.C.), University of South Florida College of Medicine, Tampa, Fla, Department of Clinical Research (W.G.S.), Campbell University
| | - Mandeep R. Mehra
- From the Department of Medicine (G.C.F.), Ahmanson-UCLA Cardiomyopathy Center, UCLA Medical Center, Los Angeles, Calif, Baylor Heart and Vascular Institute (C.W.Y.), Baylor University Medical Center, Dallas, Tex, Nursing Institute and George M. and Linda H. Kaufman Center for Heart Failure (N.M.A.), Cleveland Clinic Foundation, Cleveland, Ohio, Division of Cardiology (A.B.C.), University of South Florida College of Medicine, Tampa, Fla, Department of Clinical Research (W.G.S.), Campbell University
| | - Christopher M. O'Connor
- From the Department of Medicine (G.C.F.), Ahmanson-UCLA Cardiomyopathy Center, UCLA Medical Center, Los Angeles, Calif, Baylor Heart and Vascular Institute (C.W.Y.), Baylor University Medical Center, Dallas, Tex, Nursing Institute and George M. and Linda H. Kaufman Center for Heart Failure (N.M.A.), Cleveland Clinic Foundation, Cleveland, Ohio, Division of Cardiology (A.B.C.), University of South Florida College of Medicine, Tampa, Fla, Department of Clinical Research (W.G.S.), Campbell University
| | - Dwight Reynolds
- From the Department of Medicine (G.C.F.), Ahmanson-UCLA Cardiomyopathy Center, UCLA Medical Center, Los Angeles, Calif, Baylor Heart and Vascular Institute (C.W.Y.), Baylor University Medical Center, Dallas, Tex, Nursing Institute and George M. and Linda H. Kaufman Center for Heart Failure (N.M.A.), Cleveland Clinic Foundation, Cleveland, Ohio, Division of Cardiology (A.B.C.), University of South Florida College of Medicine, Tampa, Fla, Department of Clinical Research (W.G.S.), Campbell University
| | - Mary Norine Walsh
- From the Department of Medicine (G.C.F.), Ahmanson-UCLA Cardiomyopathy Center, UCLA Medical Center, Los Angeles, Calif, Baylor Heart and Vascular Institute (C.W.Y.), Baylor University Medical Center, Dallas, Tex, Nursing Institute and George M. and Linda H. Kaufman Center for Heart Failure (N.M.A.), Cleveland Clinic Foundation, Cleveland, Ohio, Division of Cardiology (A.B.C.), University of South Florida College of Medicine, Tampa, Fla, Department of Clinical Research (W.G.S.), Campbell University
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Bisoprolol vs. carvedilol in elderly patients with heart failure: rationale and design of the CIBIS-ELD trial. Clin Res Cardiol 2008; 97:578-86. [DOI: 10.1007/s00392-008-0681-6] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2008] [Accepted: 05/16/2008] [Indexed: 12/22/2022]
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Clinical Effects of Initial 6 Months Monotherapy with Bisoprolol versus Enalapril in the Treatment of Patients with Mild to Moderate Chronic Heart Failure. Data from the CIBIS III Trial. Cardiovasc Drugs Ther 2008; 22:399-405. [DOI: 10.1007/s10557-008-6116-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2008] [Accepted: 04/29/2008] [Indexed: 10/22/2022]
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Goode KM, Nabb S, Cleland JGF, Clark AL. A comparison of patient and physician-rated New York Heart Association class in a community-based heart failure clinic. J Card Fail 2008; 14:379-87. [PMID: 18514929 DOI: 10.1016/j.cardfail.2008.01.014] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2007] [Revised: 01/21/2008] [Accepted: 01/23/2008] [Indexed: 10/22/2022]
Abstract
OBJECTIVE The New York Heart Association (NYHA) classification is recommended for grading symptoms of chronic heart failure and is a powerful prognostic marker. Patient-rated NYHA (Pa-NYHA) and physician-rated NYHA (Dr-NYHA) class have never been compared directly, and it is unknown whether they carry similar prognostic significance. METHODS AND RESULTS NYHA class was rated independently by a physician and patient in 1752 patients referred with suspected heart failure. Pa-NYHA and Dr-NYHA varied by 1 class in 37.1% cases and by 2 classes in 12.8% cases. Mean Dr-NYHA and Pa-NYHA were higher in women than men (1.98 vs 1.89, P = .016; 2.17 vs 2.02, P = .002) despite less cardiac disease. Dr-NYHA correlated more with 6-minute walk test distance and severity of left ventricular systolic dysfunction than Pa-NYHA (Spearman's rho: -0.53 vs -0.44 and 0.32 vs 0.16). Dr-NYHA better predicted mortality when compared with Pa-NYHA (log-rank: chi(2) = 105 vs 46, both P < .001). CONCLUSION Patients rate NYHA differently from physicians, and women rate NYHA differently from men. Dr-NYHA relates more strongly to survival and severity of left ventricular systolic dysfunction, suggesting that for physicians the NYHA classification may have become a "heart failure severity score" and not as was intended, purely a measure of a patient's symptoms and functional status.
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Affiliation(s)
- Kevin M Goode
- Department of Cardiology, Castle Hill Hospital, Kingston-upon-Hull, United Kingdom
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Remme WJ, McMurray JJV, Hobbs FDR, Cohen-Solal A, Lopez-Sendon J, Boccanelli A, Zannad F, Rauch B, Keukelaar K, Macarie C, Ruzyllo W, Cline C. Awareness and perception of heart failure among European cardiologists, internists, geriatricians, and primary care physicians. Eur Heart J 2008; 29:1739-52. [PMID: 18506054 DOI: 10.1093/eurheartj/ehn196] [Citation(s) in RCA: 78] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
AIMS To assess awareness of heart failure (HF) management recommendations in Europe among cardiologists (C), internists and geriatricians (I/G), and primary care physicians (PCPs). METHODS AND RESULTS The Study group on HF Awareness and Perception in Europe (SHAPE) surveyed randomly selected C (2041), I/G (1881), and PCP (2965) in France, Germany, Italy, the Netherlands, Poland, Romania, Spain, Sweden, and the UK. Each physician completed a 32-item questionnaire about the diagnosis and treatment of HF (left ventricular ejection fraction <40%). This report provides an analysis of HF awareness among C, I/G, and PCP. Seventy-one per cent I/G and 92% C use echocardiography, and 43% I/G and 82% C use echo-Doppler as a routine diagnostic test (both P < 0.0001). In contrast, 75% PCP use signs and symptoms to diagnose HF. Fewer I/G would use an angiotensin-converting enzyme (ACE)-inhibitor in >90% of their patients (64 vs. 82% C, P < 0.0001), whereas only 47% PCP would routinely prescribe an ACE-inhibitor. Worsening HF was considered a risk of ACE-inhibitor therapy by 35% PCP. I/G and PCP consistently do not prescribe target ACE-inhibitor doses (P < 0.0001 vs. C). Only 39% I/G would use a beta-blocker in >50% of their patients (vs. 73% C, P < 0.0001). Also, only 5% PCP would always, and 35% often, prescribe a beta-blocker and reach target doses in only 7-29%. Moreover, 34% PCP and 26% I/G vs. 11% C (P < 0.0001) do not start a beta-blocker in patients with mild HF, who are already on an ACE-inhibitor and are on diuretic. In mild, stable HF, 39% PCP and 18% I/G would only prescribe diuretics, vs. 7% C (P < 0.0001). In patients with worsening HF in sinus rhythm and on an optimal ACE-inhibitor, beta-blockade and diuretics, significantly more C would add spironolactone, but I/G would more often add digoxin. CONCLUSION Although each physician group lacks complete adherence to guideline-recommended management strategies, these are used significantly less well by I, G, and PCPs, indicating the need for education of these essential healthcare providers.
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Affiliation(s)
- Willem J Remme
- Sticares Cardiovascular Research Foundation, PO Box 882, 3160 AB Rhoon, The Netherlands.
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Thoughts about death and perceived health status in elderly patients with heart failure. Eur J Heart Fail 2008; 10:608-13. [PMID: 18499518 DOI: 10.1016/j.ejheart.2008.04.011] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2007] [Revised: 04/02/2008] [Accepted: 04/24/2008] [Indexed: 11/28/2022] Open
Abstract
AIM To explore thoughts about death and perceived health status in elderly patients with heart failure during a 6 month period after a deterioration needing hospitalisation. METHODS A descriptive, mixed methods design was used. Health was measured with EuroQol-5D, thoughts about death with multiple choice and open questions. A total of 145 patients with New York Heart Association class II-IV heart failure, mean age 70 years, 70% males, were included. RESULTS During deterioration, 16% of the patients were afraid of dying and 4% had this fear very often. Fear of death did not change significantly during the 6 months after deterioration. Both during deterioration (r=0.26, P<0.01) and 6 months later (r=0.40, P<0.001), fear of death and anxiety/depression were correlated. Content analysis of the open question produced 5 categories: (1) Death as a natural part of life; (2) Death as a relief from symptoms and disability (3) Death as fearful (4) Arrangements for time after death (5) A wish for an extended life. CONCLUSION Elderly patients with heart failure had a lot of thoughts about death. Higher levels of anxiety/depression were correlated to fear of death. Many expressed death as a natural relief from suffering, others were afraid of pain, loss of independence and dignity.
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Schocken DD, Benjamin EJ, Fonarow GC, Krumholz HM, Levy D, Mensah GA, Narula J, Shor ES, Young JB, Hong Y. Prevention of heart failure: a scientific statement from the American Heart Association Councils on Epidemiology and Prevention, Clinical Cardiology, Cardiovascular Nursing, and High Blood Pressure Research; Quality of Care and Outcomes Research Interdisciplinary Working Group; and Functional Genomics and Translational Biology Interdisciplinary Working Group. Circulation 2008; 117:2544-65. [PMID: 18391114 DOI: 10.1161/circulationaha.107.188965] [Citation(s) in RCA: 385] [Impact Index Per Article: 24.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
The increase in heart failure (HF) rates throughout the developed and developing regions of the world poses enormous challenges for caregivers, researchers, and policymakers. Therefore, prevention of this global scourge deserves high priority. Identifying and preventing the well-recognized illnesses that lead to HF, including hypertension and coronary heart disease, should be paramount among the approaches to prevent HF. Aggressive implementation of evidence-based management of risk factors for coronary heart disease should be at the core of HF prevention strategies. Questions currently in need of attention include how to identify and treat patients with asymptomatic left ventricular systolic dysfunction (Stage B HF) and how to prevent its development. The relationship of chronic kidney disease to HF and control of chronic kidney disease in prevention of HF need further investigation. Currently, we have limited understanding of the pathophysiological basis of HF in patients with preserved left ventricular systolic function and management techniques to prevent it. New developments in the field of biomarker identification have opened possibilities for the early detection of individuals at risk for developing HF (Stage A HF). Patient groups meriting special interest include the elderly, women, and ethnic/racial minorities. Future research ought to focus on obtaining a much better knowledge of genetics and HF, especially both genetic risk factors for development of HF and genetic markers as tools to guide prevention. Lastly, a national awareness campaign should be created and implemented to increase public awareness of HF and the importance of its prevention. Heightened public awareness will provide a platform for advocacy to create national research programs and healthcare policies dedicated to the prevention of HF.
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Divisón J, de Rivas B, Márquez-Contreras E, Sobreviela E, Luque M. Características clínicas y manejo de pacientes hipertensos con diagnóstico de insuficiencia cardíaca en Atención Primaria en España. Estudio HICAP. Rev Clin Esp 2008; 208:124-9. [DOI: 10.1157/13115819] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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de Groote P, Isnard R, Assyag P, Clerson P, Ducardonnet A, Galinier M, Jondeau G, Leurs I, Thébaut JF, Komajda M. Is the gap between guidelines and clinical practice in heart failure treatment being filled? Insights from the IMPACT RECO survey. Eur J Heart Fail 2008; 9:1205-11. [PMID: 18023249 DOI: 10.1016/j.ejheart.2007.09.008] [Citation(s) in RCA: 94] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2007] [Revised: 07/09/2007] [Accepted: 09/25/2007] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Recent registries have shown that recommended drugs for the treatment of chronic heart failure (CHF) are under-prescribed in daily practice. AIMS To determine prescription rates of CHF drugs, and to assess predictive factors for drug prescription using data from a large panel of French cardiologists. METHODS AND RESULTS We included 1919 outpatients, with NYHA class II-IV heart failure and a left ventricular ejection fraction <40%. The most frequently prescribed drugs were diuretics (83%), angiotensin converting enzyme inhibitors (ACE-I) (71%), beta-blockers (65%), spironolactone (35%) and angiotensin receptor blockers (ARB) (21%); 61% of patients received a combination of a beta-blocker and an ACE-I or ARB. Target doses were reached in 49% of the patients for ACE-I, but in only 18% for beta-blockers and in 9% for ARBs. Multivariate analyses showed that age >75 years was an independent factor associated with under-prescription of ACE-I-ARBs, beta-blockers or spironolactone. Renal failure was associated with a lower prescription of ACE-I-ARB and spironolactone, and asthma was a predictor of under-prescription of beta-blockers. CONCLUSIONS In this contemporary survey, prescription rates of CHF drugs were higher than previously reported. However, dosages were lower than those recommended in guidelines. Age remained an independent predictor of under-prescription of CHF drugs.
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Affiliation(s)
- P de Groote
- Service de Cardiologie C, Hôpital Cardiologique, CHRU, Bd du Pr Jules Leclercq, 59037, Lille Cedex, France.
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Prospective evaluation of beta-blocker use at the time of hospital discharge as a heart failure performance measure: results from OPTIMIZE-HF. J Card Fail 2008; 13:722-31. [PMID: 17996820 DOI: 10.1016/j.cardfail.2007.06.727] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2007] [Revised: 05/17/2007] [Accepted: 06/20/2007] [Indexed: 01/14/2023]
Abstract
BACKGROUND The objective of this study was to prospectively evaluate beta-blocker use at hospital discharge as an indicator of quality of care and outcomes in patients with heart failure (HF). METHODS AND RESULTS Data from the Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure (OPTIMIZE-HF) registry for patients hospitalized with HF from 259 hospitals were prospectively collected and analyzed. HF medication contraindications, intolerance, and use at hospital discharge were assessed, along with 60- to 90-day follow-up data in a prespecified cohort. There were 20,118 patients with left ventricular systolic dysfunction. At discharge, 90.6% of patients were eligible to receive beta-blockers, and 83.7% were eligible to receive an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker. Eligible patients discharged with beta-blockers were significantly more likely to be treated at follow-up than those not discharged with beta-blockers (93.1% vs 30.5%; P < .0001). Discharge use of beta-blockers in eligible patients was associated with a significant reduction in the adjusted risk of death (hazard ratio: 0.48; 95% confidence interval: 0.32-0.74; P < .001) and death/rehospitalization (odds ratio: 0.74; 95% confidence interval: 0.55-0.99; P = .04), although we cannot completely exclude the possibility of residual confounding. CONCLUSIONS Discharge beta-blocker use in HF appeared to be well tolerated, improved treatment rates, and was associated with substantially lower postdischarge mortality risk. These data provide additional evidence that supports beta-blocker use at hospital discharge in eligible patients as an HF performance measure.
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Ignacio Pérez Calvo J, Amores Arriaga B, Torralba Cabeza M. Prescripción de betabloqueantes en la insuficiencia cardíaca. Rev Clin Esp 2008; 208:111-2; author reply 112-3. [DOI: 10.1157/13115214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Zanchetti A, Cuspidi C, Comarella L, Rosei EA, Ambrosioni E, Chiariello M, Leonetti G, Mancia G, Pessina AC, Salvetti A, Trimarco B, Volpe M, Grassivaro N, Vargiu G. Left ventricular diastolic dysfunction in elderly hypertensives: results of the APROS-diadys study. J Hypertens 2008; 25:2158-67. [PMID: 17885561 DOI: 10.1097/hjh.0b013e3282eee9cf] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND A number of patients with chronic heart failure (CHF) have diastolic but not systolic dysfunction. This occurs particularly in the elderly and in hypertension, but the prevalence of diastolic dysfunction in elderly hypertensives without CHF has never been investigated systematically. METHODS AND RESULTS The Assessment of PRevalence Observational Study of Diastolic Dysfunction (APROS-diadys) project was a cross-sectional observational study on elderly (age >/= 65 years) hypertensives without systolic dysfunction [left ventricular ejection fraction (LVEF) >/= 45%] consecutively attending hospital outpatient clinics in Italy, in order to establish the prevalence of echocardiographic signs of diastolic dysfunction according to various criteria, and to correlate them with a number of demographic and clinical characteristics. Primary criteria for diastolic dysfunction was an E/A ratio (ratio between transmitral peak velocities of E and A waves) < 0.7 or > 1.5 on echocardiographic Doppler examination. Secondary criteria were: E/A < 0.5 and deceleration time (DT) > 280 ms, or isovolumic relaxation time (IVRT) > 105 ms or pulmonary vein (PV) peak systolic/peak diastolic flow (S/D) ratio > 2.5 or PV atrial retrograde flow (PV A) > 35 cm/s. Throughout Italy, 27 447 patients were screened in 107 clinics, with 24 141 excluded according to protocol. Among the remaining 3336 patients, 754 (22.6%) had signs of CHF. After exclusion of 37 protocol violators, 2545 patients (49.0% men, mean age 70.3 years, 95.4% under antihypertensive treatment) were studied ultrasonographically. Diastolic dysfunction (primary criteria) was found in 649 (25.8%) patients. Multiple logistic regression analysis found age, gender, left ventricular mass, systolic and pulse pressures and midwall shortening fraction as significant covariates. Using secondary criteria, the prevalence of diastolic dysfunction was higher (45.6%), mostly because of IVRT > 105 ms or PVA flow > 35 cm/s. CONCLUSION CHF and diastolic dysfunction are highly prevalent in elderly hypertensives attending hospital clinics.
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Affiliation(s)
- Alberto Zanchetti
- Centro di Fisiologia Clinica, University of Milan, Ospedale Maggiore Milan, Italy.
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Abstract
Heart failure (HF) ranks among the most costly chronic diseases in developed countries. At present these countries devote 1-2% of all healthcare expenditures towards HF. In the US, these costs are estimated at $US30.2 billion for 2007. The burden of HF is greatest among the elderly, with 80% of HF hospitalizations and 90% of HF-related deaths in this cohort. As a result, approximately three-quarters of the resources for HF care are consumed by elderly patients. As demographic shifts increase the number of elderly individuals in both developed and developing nations, the resources devoted to HF care will likely further increase. Hospitalization accounts for roughly two-thirds of HF costs, but procedures, outpatient visits and medications also consume significant financial resources. HF also adversely impacts patient quality of life, and these relevant effects may not be captured in pure cost analyses. The cost effectiveness of several pharmacological interventions has been explored. In general, neurohormonal antagonists used for outpatient treatment of chronic HF are relatively cost effective, in part by reducing hospitalizations. Because HF poses such an enormous financial burden, efficient resource allocation for its management is a major societal and governmental challenge. In order to make informed decisions and allocate resources for HF care rationally, detailed data regarding costs and resource use will be essential. Further studies are needed to examine the impact of pharmacological and non-pharmacological interventions on costs and resource use in elderly individuals with HF.
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Affiliation(s)
- Lawrence Liao
- The Duke Clinical Research Institute, Durham, NC, USA.
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Binkley PF, Lesinski A, Ferguson JP, Hatton PS, Yamokoski L, Hardikar S, Cooke GE, Leier CV. Recovery of normal ventricular function in patients with dilated cardiomyopathy: predictors of an increasingly prevalent clinical event. Am Heart J 2008; 155:69-74. [PMID: 18082492 DOI: 10.1016/j.ahj.2007.08.010] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2007] [Accepted: 08/12/2007] [Indexed: 10/22/2022]
Abstract
BACKGROUND This investigation was designed to identify clinical variables associated with recovery of normal ventricular function in patients with dilated cardiomyopathy treated with medical therapy. Recovery of normal ventricular function with medical treatment of patients with dilated cardiomyopathy is observed with increasing frequency. However, the clinical variables associated with such dramatic improvement of ventricular performance are poorly defined. METHODS Fifty-three patients with dilated cardiomyopathy and reduced ejection fractions who achieved an increase in ejection fraction to > or = 40% with medical therapy were identified during follow-up in a dedicated heart failure clinic. A cohort of patients frequency-matched on baseline ejection fraction who did not recover ventricular systolic function to this magnitude constituted the control group. Clinical variables characterizing the 2 groups were compared by univariable analysis. Variables that significantly differed between the 2 groups were entered in a stepwise logistic regression analysis to identify factors independently associated with recovery of ejection fraction to > or = 40%. RESULTS In the final logistic regression model, QRS duration, sex, etiology of cardiomyopathy, diabetes, and systolic blood pressure were significantly associated with improvement of ejection fraction to > or = 40%. CONCLUSIONS Five clinical variables that are independently associated with improvement of left ventricular ejection fraction to normal or near-normal values with medical therapy alone were identified by this modeling process. These variables may be used to discriminate between patients in whom ventricular function will normalize with medical therapy alone and those who will require more aggressive pharmacologic or device therapy.
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Matthews JC, Johnson ML, Koelling TM. The impact of patient-specific quality-of-care report cards on guideline adherence in heart failure. Am Heart J 2007; 154:1174-83. [PMID: 18035092 DOI: 10.1016/j.ahj.2007.08.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2006] [Accepted: 08/07/2007] [Indexed: 11/26/2022]
Abstract
BACKGROUND It is unknown if physician education through heart failure (HF) patient-specific quality-of-care report cards (HFRC) impacts outpatient HF guideline adherence. METHODS A prospective pre-post design study was performed to test the hypothesis that a one-time, patient-specific HFRC delivered to physicians after HF patient (ejection fraction < or = 40%) discharge would lead to improved HF guideline adherence compared with control practitioners. Patients were contacted at 1, 3, and 6 months after discharge to assess medication usage and intolerances. Six month quality score (QS) was the primary end point, calculated as the sum of adherence to 4 medication performance measures (angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, beta-blockers, aldosterone inhibitors, and warfarin for atrial fibrillation). RESULTS The mean QS at discharge was 3.10 +/- 0.78 in controls (n = 189) and 3.25 +/- 0.79 in the HFRC group (n = 76, P = .11). Controlling for discharge QS, the HFRC resulted in a significantly improved QS at 3 months (beta = .11, P = .023) but not at the 6-month primary end point (beta = .084, P = .14). Controlling for baseline medication use, patients of practitioners receiving the HFRC were 32.5 (P = .019) and 8.5 (P = .030) times more likely to receive, or have a documented contraindication to, an angiotensin-converting enzyme inhibitor/angiotensin receptor blocker at 3 and 6 months, respectively. There were no significant differences in indicated beta-blocker, aldosterone inhibitor, or warfarin prescriptions at any follow-up. CONCLUSIONS Although one-time patient-specific report cards result in short-term statistically significant improvements in outpatient evidence-based HF care, the gain does not translate into sustained improvements in quality of care.
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Lainscak M, Cleland JGF, Lenzen MJ, Nabb S, Keber I, Follath F, Komajda M, Swedberg K. Recall of lifestyle advice in patients recently hospitalised with heart failure: A EuroHeart Failure Survey analysis. Eur J Heart Fail 2007; 9:1095-103. [PMID: 17888721 DOI: 10.1016/j.ejheart.2007.08.001] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2006] [Revised: 06/03/2007] [Accepted: 08/15/2007] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND There are limited data on recall and implementation of lifestyle advice in patients with heart failure (HF). AIM To investigate what advice patients with HF recall being given, and whether they report following the advice they remember. METHODS AND RESULTS 3261 patients with suspected HF participating in the EuroHeart Failure Survey were interviewed by a health professional 12 weeks after hospital discharge. Patients recalled receiving 46% of pre-specified items of advice and 67% reported that they followed these completely. Both recall (53%) and implementation (71%) was best in patients with left ventricular systolic dysfunction (LVSD). In multivariate analysis, younger age, male sex, patient awareness of the condition and patients reporting that they received a clear explanation of the diagnosis by a health professional, all factors associated with having LVSD, were the strongest predictors of recall. CONCLUSIONS Recall of and adherence to advice by patients with HF in this large European cross-sectional survey was disappointing. Responsibility for patient education lies with health professionals who should ensure that patients receive and understand advice, and are able to recall and follow it. A greater awareness of the issues surrounding lifestyle advice and more evidence supporting its value could improve patient care.
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Affiliation(s)
- Mitja Lainscak
- Department of Internal Medicine, General Hospital Murska Sobota, Murska Sobota, Slovenia.
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Guideline adherence for pharmacotherapy of chronic systolic heart failure in general practice: a closer look on evidence-based therapy. Clin Res Cardiol 2007; 97:244-52. [DOI: 10.1007/s00392-007-0617-6] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2007] [Accepted: 10/17/2007] [Indexed: 11/26/2022]
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Beta Blockers or Angiotensin-Converting-Enzyme Inhibitor/Angiotensin Receptor Blocker: What Should Be First? Cardiol Clin 2007; 25:581-94; vii. [DOI: 10.1016/j.ccl.2007.09.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Remme WJ. Filling the gap between guidelines and clinical practice in heart failure treatment: still a far cry from reality. Eur J Heart Fail 2007; 9:1143-5. [PMID: 17936067 DOI: 10.1016/j.ejheart.2007.08.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2007] [Accepted: 08/30/2007] [Indexed: 11/29/2022] Open
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Lainscak M, Moullet C, Schön N, Tendera M. Treatment of chronic heart failure with carvedilol in daily practice: the SATELLITE survey experience. Int J Cardiol 2007; 122:149-55. [PMID: 17804098 DOI: 10.1016/j.ijcard.2007.08.001] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2006] [Revised: 07/06/2007] [Accepted: 08/11/2007] [Indexed: 10/22/2022]
Abstract
BACKGROUND Beta-blockers are well established for treatment of chronic heart failure (CHF). However, the extent of implementation of trial results and guidelines in daily practice remains limited, and information regarding how patients feel is scarce. METHODS In this prospective observational survey of 6 months duration, 531 physicians from 10 countries recruited 3748 beta-blockers untreated patients with CHF. We assessed the efficacy, tolerability and achieved dosage of carvedilol. In addition, patients assessed their well-being 3 times: at baseline, after 3 and 6 months of treatment. RESULTS Carvedilol was started in 3721 patients with CHF (median age 65 years, 60% men). NYHA class, clinical symptoms and signs, vital signs, 5-item well-being rating scale and visual analogue scale improved during the survey. Side effects, mostly fatigue, hypotension, and dizziness, were reported for 6.5% and 5% of patients at 3 and 6 months and carvedilol had to be discontinued in 63 patients. A total of 55 deaths (1.5%) and 520 hospitalisations in 466 patients (13%) were recorded. At 6 months the mean daily dose of carvedilol was 31+/-11 mg; 25 mg/day was prescribed to 35% and 50 mg/day to 26% of patients. CONCLUSIONS Initiation and up-titration of carvedilol in ambulatory care patients with CHF is feasible and safe. Its efficacy and tolerability were at least as good as in clinical trials, while the amelioration of patients' well-being was significant despite sub-optimal dosing. An additional effort should be done by physicians to treat their patients with CHF in daily practice with the recommended beta-blockers at optimal doses.
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Affiliation(s)
- Mitja Lainscak
- Department of Internal Medicine, General Hospital Murska Sobota, Murska Sobota, Slovenia.
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Peters-Klimm F, Müller-Tasch T, Schellberg D, Gensichen J, Muth C, Herzog W, Szecsenyi J. Rationale, design and conduct of a randomised controlled trial evaluating a primary care-based complex intervention to improve the quality of life of heart failure patients: HICMan (Heidelberg Integrated Case Management). BMC Cardiovasc Disord 2007; 7:25. [PMID: 17716364 PMCID: PMC1995216 DOI: 10.1186/1471-2261-7-25] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2007] [Accepted: 08/23/2007] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Chronic congestive heart failure (CHF) is a complex disease with rising prevalence, compromised quality of life (QoL), unplanned hospital admissions, high mortality and therefore high burden of illness. The delivery of care for these patients has been criticized and new strategies addressing crucial domains of care have been shown to be effective on patients' health outcomes, although these trials were conducted in secondary care or in highly organised Health Maintenance Organisations. It remains unclear whether a comprehensive primary care-based case management for the treating general practitioner (GP) can improve patients' QoL. METHODS/DESIGN HICMan is a randomised controlled trial with patients as the unit of randomisation. Aim is to evaluate a structured, standardized and comprehensive complex intervention for patients with CHF in a 12-months follow-up trial. Patients from intervention group receive specific patient leaflets and documentation booklets as well as regular monitoring and screening by a prior trained practice nurse, who gives feedback to the GP upon urgency. Monitoring and screening address aspects of disease-specific self-management, (non)pharmacological adherence and psychosomatic and geriatric comorbidity. GPs are invited to provide a tailored structured counselling 4 times during the trial and receive an additional feedback on pharmacotherapy relevant to prognosis (data of baseline documentation). Patients from control group receive usual care by their GPs, who were introduced to guideline-oriented management and a tailored health counselling concept. Main outcome measurement for patients' QoL is the scale physical functioning of the SF-36 health questionnaire in a 12-month follow-up. Secondary outcomes are the disease specific QoL measured by the Kansas City Cardiomyopathy questionnaire (KCCQ), depression and anxiety disorders (PHQ-9, GAD-7), adherence (EHFScBS and SANA), quality of care measured by an adapted version of the Patient Chronic Illness Assessment of Care questionnaire (PACIC) and NT-proBNP. In addition, comprehensive clinical data are collected about health status, comorbidity, medication and health care utilisation. DISCUSSION As the targeted patient group is mostly cared for and treated by GPs, a comprehensive primary care-based guideline implementation including somatic, psychosomatic and organisational aspects of the delivery of care (HICMAn) is a promising intervention applying proven strategies for optimal care.
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Affiliation(s)
- Frank Peters-Klimm
- Department of General Practice and Health Services Research, University Hospital of Heidelberg, Voßstraße 2, 69115 Heidelberg, Germany
| | - Thomas Müller-Tasch
- Department of Psychosomatic and General Internal Medicine, University of Heidelberg Hospital, Germany
| | - Dieter Schellberg
- Department of Psychosomatic and General Internal Medicine, University of Heidelberg Hospital, Germany
| | - Jochen Gensichen
- Institute for General Practice, Chronic Care and Health Services Research University of Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt a. M., Germany
| | - Christiane Muth
- Institute for General Practice, Chronic Care and Health Services Research University of Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt a. M., Germany
| | - Wolfgang Herzog
- Department of Psychosomatic and General Internal Medicine, University of Heidelberg Hospital, Germany
| | - Joachim Szecsenyi
- Department of General Practice and Health Services Research, University Hospital of Heidelberg, Voßstraße 2, 69115 Heidelberg, Germany
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May CR, Mair FS, Dowrick CF, Finch TL. Process evaluation for complex interventions in primary care: understanding trials using the normalization process model. BMC FAMILY PRACTICE 2007; 8:42. [PMID: 17650326 PMCID: PMC1950872 DOI: 10.1186/1471-2296-8-42] [Citation(s) in RCA: 108] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/09/2007] [Accepted: 07/24/2007] [Indexed: 11/10/2022]
Abstract
BACKGROUND The Normalization Process Model is a conceptual tool intended to assist in understanding the factors that affect implementation processes in clinical trials and other evaluations of complex interventions. It focuses on the ways that the implementation of complex interventions is shaped by problems of workability and integration. METHOD In this paper the model is applied to two different complex trials: (i) the delivery of problem solving therapies for psychosocial distress, and (ii) the delivery of nurse-led clinics for heart failure treatment in primary care. RESULTS Application of the model shows how process evaluations need to focus on more than the immediate contexts in which trial outcomes are generated. Problems relating to intervention workability and integration also need to be understood. The model may be used effectively to explain the implementation process in trials of complex interventions. CONCLUSION The model invites evaluators to attend equally to considering how a complex intervention interacts with existing patterns of service organization, professional practice, and professional-patient interaction. The justification for this may be found in the abundance of reports of clinical effectiveness for interventions that have little hope of being implemented in real healthcare settings.
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Affiliation(s)
- Carl R May
- Institute of Health and Society, Newcastle University, 21 Claremont Place, Newcastle upon Tyne, NE2 4AA, UK
| | - Frances S Mair
- Division of General Practice and Primary Care, University of Glasgow, Glasgow, UK
| | - Christopher F Dowrick
- School of Population, Community and Behavioural Sciences, University of Liverpool, Liverpool UK
| | - Tracy L Finch
- Institute of Health and Society, Newcastle University, 21 Claremont Place, Newcastle upon Tyne, NE2 4AA, UK
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Fonarow GC, Yancy CW, Albert NM, Curtis AB, Stough WG, Gheorghiade M, Heywood JT, Mehra M, O'Connor CM, Reynolds D, Walsh MN. Improving the use of evidence-based heart failure therapies in the outpatient setting: the IMPROVE HF performance improvement registry. Am Heart J 2007; 154:12-38. [PMID: 17584548 DOI: 10.1016/j.ahj.2007.03.030] [Citation(s) in RCA: 87] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2005] [Accepted: 03/18/2007] [Indexed: 10/23/2022]
Abstract
Evidence-based consensus treatment guidelines are available to assist physicians with the management of chronic heart failure (HF). Although it has been generally presumed that physicians incorporate these treatment guidelines into clinical practice, the actual assimilation of evidence-based strategies and guidelines has been demonstrated to be less than ideal. Studies of HF care show that treatment guidelines are slowly adopted and inconsistently applied and, thus, often fail to lead to improvements in patient care and outcomes. There are a number of ongoing, large, national quality improvement registries that are following the clinical care and outcomes of inpatient HF treatment. However, to date, there have been no similar quality improvement registries in the outpatient arena. The Registry to Improve the Use of Evidence-Based Heart Failure Therapies in the Outpatient Setting (IMPROVE HF) is the first large, comprehensive performance improvement registry designed to characterize the current outpatient management of systolic HF and assess the effect of practice-specific process improvement interventions consisting of education, specific clinical guidelines, reminder systems, benchmarked quality reports, and structured academic detailing on the use of evidence-based HF therapies. Seven performance measures to quantify the quality of outpatient HF care were explicitly developed by the IMPROVE HF Steering Committee. The primary objective is to observe, over the aggregate of IMPROVE HF practice sites, a relative > or = 20% improvement in at least 2 of the 7 performance measures at 24 months, compared with baseline. Deidentified clinical data from the medical records of a planned 43,000 patients from 160 US cardiology practices will be included in this study.
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Affiliation(s)
- Gregg C Fonarow
- Department of Medicine, Ahmanson-UCLA Cardiomyopathy Center, Los Angeles, CA 90095-1679, USA.
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Rodríguez Roca GC, Barrios Alonso V, Aznar Costa J, Llisterri Caro JL, Alonso Moreno FJ, Escobar Cervantes C, Lou Arnal S, Divisón Garrote JA, Murga Eizagaechevarría N, Matalí Gilarranz A. Características clínicas de los pacientes diagnosticados de insuficiencia cardíaca crónica asistidos en Atención Primaria. Estudio CARDIOPRES. Rev Clin Esp 2007; 207:337-40. [PMID: 17662198 DOI: 10.1016/s0014-2565(07)73402-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Scarce information is available on the clinical characteristics and risk factors of patients with chronic heart failure (CHF) attended in Primary Care (PC) setting. The aim of this study was to analyze the clinical characteristics of this population in PC. PATIENTS AND METHODS Multicenter, cross-sectional study in patients with CHF, consecutively recruited by 232 physicians in PC. The collected data included sociodemographic, etiologic, clinical and therapeutic variables. RESULTS Eight hundred forty seven (847) patients were included (age 73.0 +/- 9.6 years; 50.5% men). Of these, 84.3% had arterial hypertension (AHT), 59.2% hypercholesterolemia and 34.9% diabetes mellitus. The most frequent associated clinical disorders were ischemic heart disease (40.1%) and peripheral artery disease (28.6%). In 69.6% of the patients the physicians knew the type of dysfunction (32.4% systolic, 37.2% diastolic). The main etiologies of CHF were the hypertensive cardiomyopathy (75.0%) and ischemic heart disease (40.1%); the most frequent trigger factor was atrial fibrillation (43.9%). Loop diuretics (72.3%) and angiotensin-converting enzyme inhibitors (60.9%) were the treatments used most and 6.7% of the patients were receiving treatment with beta blockers. CONCLUSIONS AHT appears to be primary cause of CHF in PC. Diastolic dysfunction is more frequent than the systolic one, and the PC physicians do not know the cause of the ventricular dysfunction in one third of the cases. Loop diuretics and angiotensin-converting enzyme inhibitors were the most frequently used in these patients; the use of beta blockers in CHF is very scarce in PC.
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Cleland J, Tageldien A, Khaleva O, Hobson N, Clark AL. Should Patients who have Persistent Severe Symptoms Receive a Left Ventricular Assist Device or Cardiac Resynchronization Therapy as the Next Step? Heart Fail Clin 2007; 3:267-73. [DOI: 10.1016/j.hfc.2007.05.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Houde S, Feldman DE, Pilote L, Beck EJ, Giannetti N, Frenette M, Ducharme A. Are there sex-related differences in specialized, multidisciplinary congestive heart failure clinics? Can J Cardiol 2007; 23:451-5. [PMID: 17487289 PMCID: PMC2650664 DOI: 10.1016/s0828-282x(07)70783-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
BACKGROUND Specialized, multidisciplinary clinics improve service provision and reduce morbidity for patients with congestive heart failure (CHF). Although sex-related differences in access to cardiac health services have been reported, it remains unclear whether there are sex-related differences in the use of these specialized services. OBJECTIVES To evaluate possible sex-related differences in severity at entry into specialized, multidisciplinary clinics, and compare prescription patterns between male and female patients at these clinics. METHODS Data were obtained from the electronic clinical files of 765 CHF patients newly admitted to any of three main CHF clinics in Montreal, Quebec. Univariate and multivariate models were used to compare differences between sexes. RESULTS Only 27.1% of patients were female. The mean age (+/- SD) of the women in the present study was similar to that of the men (64+/-16 years versus 65+/-13 years, respectively). Left ventricular ejection fraction at entry for patients with reduced systolic function was comparable between sexes. The New York Heart Association functional class at entry was similar among men and women with systolic dysfunction. However, among patients with preserved systolic function, women were more symptomatic, with a higher functional class at entry (adjusted OR 2.52, 95% CI 1.18 to 5.38). Prescription profiles were similar for men and women. CONCLUSION Entry into a clinic may be delayed for women with preserved systolic function CHF. However, clinic referral patterns and disease management appeared to be similar among both men and women with systolic dysfunction CHF.
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Affiliation(s)
- Stefanie Houde
- Université de Montréal
- Direction de Santé Publique de Montréal
| | - Debbie Ehrmann Feldman
- Université de Montréal
- Direction de Santé Publique de Montréal
- Correspondence: Dr Debbie Ehrmann Feldman, 1301 Sherbrooke Street East, Montreal, Quebec H2L 1M3. Telephone 514-528-2400, fax 514-528-2512, e-mail
| | | | - Eduard J Beck
- Direction de Santé Publique de Montréal
- McGill University
| | | | - Marc Frenette
- Université de Montréal
- Hôpital du Sacré-Cœur de Montréal
| | - Anique Ducharme
- Université de Montréal
- Institut de Cardiologie de Montréal, Montreal, Quebec
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Sturm HB, van Gilst WH, Veeger N, Haaijer-Ruskamp FM. Prescribing for chronic heart failure in Europe: does the country make the difference? A European survey. Pharmacoepidemiol Drug Saf 2007; 16:96-103. [PMID: 16528759 DOI: 10.1002/pds.1216] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
PURPOSE International differences in prescribing patterns for chronic heart failure (CHF) have been demonstrated repeatedly. It is not clear whether these differences arise entirely from patient characteristics or factors related to the country itself, such as health care systems or culture. We aim to assess the role of countries in this international variation, aside from the role of patient characteristics. METHODS In this European primary care practice survey (from 1999/2000) 11062 CHF patients from 14 countries were included. The influence of country (corrected for patient characteristics) on prescribed drug regimes was assessed by multinomial logistical regression. RESULTS Prescribing of guideline-recommended drug regimes ranged from 28.1% in Turkey to 61.8% in Hungary. Including additional regimes justifiable by patients' co-morbidities, increased overall 'rational' prescribing by 11%, but differences among countries remained similar. Multivariate analysis for one-drug and two-drug regimes explained between 35% and 42% of the total variance, country contributed 7%-8% (p < 0.005). Countries determined the number of drugs used and the likelihood of individual drug regimes. For example, in Czech Republic digoxin alone was more likely to be given than the recommended ACE-inhibitors (OR: 3.45; 95%CI: 2.56-4.64), while the combination of digoxin with ACE-inhibitors was as likely as the recommended combination of ACE-inhibitors and beta-blockers (OR: 1.17; 95%CI: 0.88-1.55). CONCLUSION Country of residence clearly influenced prescribed drug volume and choice of drug regimes. Therefore, optimal CHF management cannot be achieved without considering country specific factors. It remains to be established which factors within health-care systems are responsible for these effects.
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Affiliation(s)
- H B Sturm
- Department of Clinical Pharmacology, University Medical Center Groningen, Groningen, The Netherlands.
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Williams RE. Early Initiation of β Blockade in Heart Failure: Issues and Evidence. J Clin Hypertens (Greenwich) 2007; 7:520-8; quiz 529-30. [PMID: 16227771 PMCID: PMC8109715 DOI: 10.1111/j.1524-6175.2005.04273.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Despite clinical trials demonstrating that inhibitors of the renin-angiotensin and sympathetic nervous systems can reduce the mortality and morbidity risk associated with heart failure, these drugs have remained underutilized in general clinical practice. In particular, many patients with heart failure due to left ventricular systolic dysfunction fail to receive beta blockers, although this class of drugs, as well as other antihypertensive agents such as angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, are recommended as part of routine heart failure therapy by national expert consensus guidelines. In-hospital initiation of beta-blocker therapy may improve long-term utilization by physicians and compliance by patients through obviating many of the misperceived dangers associated with beta blockade. The following review of the clinical trial data from the Randomized Evaluation of Strategies for Left Ventricular Dysfunction (RESOLVD) trial, the Metoprolol Controlled-Release Randomized Intervention Trial in Heart Failure (MERIT-HF), the Cardiac Insufficiency Bisoprolol Study II (CIBIS-II), the Carvedilol Prospective Randomized Cumulative Survival (COPERNICUS) trial, and the Initiation Management Predischarge Process for Assessment of Carvedilol Therapy for Heart Failure (IMPACT-HF) trial on the efficacy, safety, and tolerability of beta blockers indicates that early initiation can be safely achieved and can improve patient outcomes.
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Yancy CW. Heart Failure and Its Management With ?-Blockade: Potential Applications of Once-Daily Therapy. J Clin Hypertens (Greenwich) 2007. [DOI: 10.1111/j.1524-6175.2007.06580.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Otero-Raviña F, Grigorian-Shamagian L, Fransi-Galiana L, Názara-Otero C, Fernández-Villaverde JM, del Álamo-Alonso A, Nieto-Pol E, de Santiago-Boullón M, López-Rodríguez I, Cardona-Vidal JM, Varela-Román A, González-Juanatey JR. Estudio gallego de insuficiencia cardiaca en atención primaria (estudio GALICAP). Rev Esp Cardiol 2007. [DOI: 10.1157/13101641] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Patel P, White DL, Deswal A. Translation of clinical trial results into practice: temporal patterns of beta-blocker utilization for heart failure at hospital discharge and during ambulatory follow-up. Am Heart J 2007; 153:515-22. [PMID: 17383287 DOI: 10.1016/j.ahj.2007.01.037] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2006] [Accepted: 01/21/2007] [Indexed: 01/30/2023]
Abstract
BACKGROUND Underutilization of beta-blockers in heart failure (HF) has been widely reported at hospital discharge and in the ambulatory setting. We examined recent temporal patterns of beta-blocker utilization in HF with systolic dysfunction at hospital discharge and over 2-year follow-up. METHODS Annual trends of beta-blocker use were examined in a clinical database of patients with ejection fraction < or = 40% discharged after HF hospitalization in 1998-2004 (n = 735). More detailed data on beta-blocker use at discharge and over 2-year follow-up were abstracted for 200 consecutive patients each in 1999-2001 and 2003-2004. RESULTS Annual rates of beta-blocker use at discharge increased steadily by 10% per year from 1998-2004 (P < .001), with no sharp increase noted in any single year after publication of clinical trials or guidelines. Use among patients without contraindications increased markedly from 1999-2001 to 2003-2004 at hospital discharge (38.7% vs 82.6%, P < .001) and 2-year follow-up (53.0% vs 84.5%, P < .001). The increase was significant in all examined subgroups. Although > 50% of patients remained on low doses of beta-blockers, a greater proportion trended to reach target doses at 2 years in the later period (25.6% vs 12.5%, P = .13). CONCLUSIONS Substantial increase in beta-blocker utilization in HF with systolic dysfunction occurred from 1998 to 2004, demonstrating that high rates of beta-blocker use are being achieved at hospital discharge and maintained in the ambulatory setting after discharge. However, the time lag in translation of scientific evidence into maximal use of beneficial therapy in practice remains a target for quality improvement.
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Affiliation(s)
- Parag Patel
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
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Lainscak M, Cleland JGF, Lenzen MJ, Keber I, Goode K, Follath F, Komajda M, Swedberg K. Nonpharmacologic measures and drug compliance in patients with heart failure: data from the EuroHeart Failure Survey. Am J Cardiol 2007; 99:31D-37D. [PMID: 17378994 DOI: 10.1016/j.amjcard.2006.12.018] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Advice on lifestyle, diet, vaccination, and therapy are part of the standard management of heart failure (HF). However, there is little information on whether patients with HF recall receiving such recommendations and, if so, whether they report following them. We obtained information on the recall of and adherence to nonpharmacologic advice from patients enrolled in the EuroHeart Failure Survey. This article focuses on 2,331 patients who had a clinical diagnosis of HF during the index admission and attended an interview 12 weeks after discharge. Their mean age was 67 +/- 12 years and 38% were women. Patients recalled receiving 4.1 +/- 2.7 items of advice with higher rates in Central Europe and the Mediterranean region. Recall of dietary advice (cholesterol or fat intake, 63%; dietary salt, 60%) was higher than for some other interventions (influenza vaccination, 36%; avoidance of nonsteroidal anti-inflammatory drugs, 17%). Among those who recalled the advice, a substantial proportion indicated that they did not follow advice completely (cholesterol and fat intake, 61%; dietary salt, 63%; influenza vaccination, 75%; avoidance of nonsteroidal anti-inflammatory drugs, 80%), although few patients indicated they ignored the advice completely. Patients who recalled >4 items versus < or =4 items of advice were younger and more often received angiotensin-converting enzyme inhibitors (71% vs 62%), beta-blockers (51% vs 38%), and spironolactone (25% vs 21%). In conclusion, after hospitalization for HF, many patients do not recall nonpharmacologic advice. In addition, a substantial proportion of those who recall the advice follow it incompletely. Younger age and prescription of appropriate pharmacologic treatment are associated with higher rates of recall and implementation.
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Affiliation(s)
- Mitja Lainscak
- Department of Internal Medicine, General Hospital Murska Sobota, Murska Sobota, Slovenia.
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De Keulenaer GW, Brutsaert DL. Systolic and diastolic heart failure: Different phenotypes of the same disease? Eur J Heart Fail 2007; 9:136-43. [PMID: 16884955 DOI: 10.1016/j.ejheart.2006.05.014] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2005] [Revised: 02/20/2006] [Accepted: 05/24/2006] [Indexed: 11/16/2022] Open
Abstract
Traditional pathophysiological concepts of chronic heart failure have largely focused on the haemodynamic consequences of ventricular systolic dysfunction. How these concepts relate to the pathophysiology of diastolic heart failure, i.e., heart failure with a preserved ejection fraction is, however, unclear, causing uncertainty about pathophysiology, diagnosis and management. Recent measurements of regional myocardial systolic function in patients with diastolic heart failure indicate that systolic and diastolic heart failure may be more closely related than previously anticipated. Rather than being considered as separate diseases with a distinct pathophysiology, systolic and diastolic heart failure may be merely different clinical presentations within a phenotypic spectrum of one and the same disease. In this review, we will interpret these new insights in a broader conceptual context of chronic heart failure and design novel paradigms in which systolic and diastolic heart failure jointly progress in a pathophysiological time trajectory of only one disease.
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