Opportunities for improvement in the diagnosis and treatment of heart failure

Nurse-Led Multidisciplinary Heart Failure Group Clinic Appointments: Methods, Materials, and Outcomes Used in the Clinical Trial

BACKGROUND

The Self-management and Care of Heart Failure through Group Clinics Trial evaluated the effects of multidisciplinary group clinic appointments on self-care skills and rehospitalizations in high-risk heart failure (HF) patients.

OBJECTIVE

The purpose of this article is to (1) describe key Self-management and Care of Heart Failure through Group Clinics Trial group clinic interactive learning strategies, (2) describe resources and materials used in the group clinic appointment, and (3) present results supporting this patient-centered group intervention.

METHODS

This clinical trial included 198 HF patients (randomized to either group clinical appointments or to standard care). Data were collected from 72 group clinic appointments via patients' (1) group clinic session evaluations, (2) HF self-care behaviors skills, (3) HF-related discouragement and quality of life scores, and (4) HF-related reshopitalizations during the 12-month follow-up. Also, the costs of delivery of the group clinical appointments were tabulated.

RESULTS

Overall, patients rated group appointments as 4.8 of 5 on the "helpfulness" in managing HF score. The statistical model showed a 33% decrease in the rate of rehospitalizations (incidence rate ratio, 0.67) associated with the intervention over the 12-month follow-up period when compared with control patients (χ(2)1=3.9, P=.04). The total cost for implementing 5 group appointments was $243.58 per patient.

CONCLUSION

The intervention was associated with improvements in HF self-care knowledge and home care behavior skills and managing their for HF care. In turn, better self-care was associated with reductions in HF-related hospitalizations.

Low serum triglyceride levels as predictors of cardiac death in heart failure patients

Understanding the influence of sex differences on predictors of cardiac mortality rates in chronic heart failure might enable us to lengthen lifetimes and to improve lives. This study describes the influence of sex on cardiovascular mortality rates among chronic heart failure patients. From January 2003 through December 2009, we evaluated 637 consecutive patients (409 men and 228 women) with chronic heart failure, who ranged in age from 18 through 94 years (mean age, 64 ± 13 yr) and ranged in New York Heart Association (NYHA) functional class from II through IV. The mean follow-up period was 38 ± 15 months, the mean age was 64 ± 13 years, and the mean left ventricular ejection fraction was 0.27 ±0.11. By the end of the study, both sexes had similar cardiovascular mortality rates (36% men vs 37% women, P=0.559). In Cox regression analysis, NYHA functional class, triglyceride level, and history of coronary artery disease were independent predictors of cardiovascular death for women with chronic heart failure. For men with chronic heart failure, the patient's age, ejection fraction, and sodium level were independent predictors of cardiovascular death. In a modern tertiary referral heart failure clinic, decreased triglyceride levels were, upon univariate analysis, predictors of poor outcomes for both men and women. However, upon Cox regression analysis, reduced triglyceride levels were independent predictors of cardiac death only in women.

Natriuretic peptides: Diagnostic and therapeutic use

Natriuretic peptides (NPs) are hormones which are mainly secreted from heart and have important natriuretic and kaliuretic properties. There are four different groups NPs identified till date [atrial natriuretic peptide (ANP), B-type natriuretic peptide (BNP), C-type natriuretic peptide (CNP) and dendroaspis natriuretic peptide, a D-type natriuretic peptide (DNP)], each with its own characteristic functions. The N-terminal part of the prohormone of BNP, NT-proBNP, is secreted alongside BNP and has been documented to have important diagnostic value in heart failure. NPs or their fragments have been subjected to scientific observation for their diagnostic value and this has yielded important epidemiological data for interpretation. However, little progress has been made in harnessing the therapeutic potential of these cardiac hormones.

Influence of gender on long-term prognosis of patients with chronic heart failure seen in heart failure clinics

BACKGROUND

Controversy exists concerning the influence of gender in the prognosis of patients with heart failure and no evidence is available from specific heart failure clinics.

HYPOTHESIS

Women with ambulatory heart failure are managed differently than men, although their prognosis might be better than men.

METHODS AND RESULTS

We analyzed the clinical characteristics, complementary test results, treatment, and prognosis in 4720 patients with chronic heart failure seen in 62 specialized clinics forming part of a multicenter registry during a mean follow-up of 40 months. The mean age was 65 +/- 12 years and 71% were men. The men were younger than the women and more often had a history of hyperlipidemia and ischemic heart disease. The men had a more advanced heart failure New York Heart Association (NYHA) functional class (III-IV) than the women and a greater frequency of systolic ventricular dysfunction. The men more often received treatment with beta-blockers, vasodilators, and antiplatelet aggregators as well as higher mean doses as compared with the women. The overall survival after the follow-up was similar for both genders, although the women had lower rates of survival free of admission for heart failure.

CONCLUSIONS

Despite the mortality of women and men with heart failure being similar, the rate of readmission for heart failure is greater in women in specialized heart failure clinics. These results may be associated with the pharmacological treatment differences observed.

[New biohumoral markers of differential diagnosis in patients with suspected heart failure]

INTRODUCTION

In the regular clinic practice, the assessment of the cause of dispnea is a dilemma which has a significant implication in both the estimation of prognosis and treatment of the patient. In emergency cases, when most necessary, it is often very difficult to determine whether dispnea was caused by a heart or lung disease.

ROLE OF NATRIURETIC PEPTIDE IN PATIENTS WITH DISPNEA

An acute patient with dispnea might suffer serious consequences of inadequately established diagnosis so congestive heart failure (CHE) has to be diagnosed quickly and precisely in the ER. Unfortunately, symptoms and signs of CHF are unspecific, it is sometimes impossible to obtain an adequate anamnesis and diagnosic procedures currently applied are either insufficiently precise or provide scarce information or can not always be performed under appropriate conditions. On the basis of previous findings, it has been proved that brain natriuretic peptide (BNP) can considerably contribute to the establishment of correct diagnosis as well as to the possibility of introducing an adequate therapy for those patients. However, the real value of those peptides should be estimated in relation to other clinical manifestations and indicators and the specifics of examined patients including the age, gender and the presence or absence of pulmonary or renal diseases.

NATRIURETIC PEPTIDE IN ACCESSEMENT GRADIENT OF HEART FAILURE

Determination of natriuretic peptide has represented most probably the greatest progress in diagnosing the heart failure since the introduction of echocardiography into practice. Its high sensitivity and negative predicted value makes it a valid test for excluding congestive heart failure with a very high degree of certainty.

The Role of Hospitalists in the Management of Acute Decompensated Heart Failure

Heart failure and episodes of acute decompensated heart failure have an important effect on the US health care system, especially the elderly Medicare population. Efforts to improve the quality of care for patients hospitalized with acute decompensated heart failure have focused on creating standardized treatment guidelines based on substantial clinical evidence, but inadequate implementation of these guidelines continues to result in excess morbidity and mortality from heart failure. Hospitalists specializing in inpatient treatment strategies may play an important role in implementing clinical guidelines because their main commitment is to overall clinical treatment of inpatients. This review focuses on current recommended guidelines for diagnosis, treatment, and long-term management of patients with acute decompensated heart failure and the hospitalist's role in providing the oversight needed to adhere to these guidelines and manage this complex disease state.

Science review: natriuretic peptides in critical illness

The present review will cover the mechanisms of release and the potential pathophysiological role of different natriuretic peptides in critically ill patients. By focusing on the cardiovascular system, possible implications of natriuretic peptides for diagnosis and treatment will be presented. In critical illness such as sepsis, trauma or major surgery, systemic hypotension and an intrinsic myocardial dysfunction occur. Impairment of the cardiovascular system contributes to poor prognosis in severe human sepsis. Natriuretic peptides have emerged as valuable marker substances to detect left ventricular dysfunction in congestive heart failure of different origins. Increased plasma levels of circulating natriuretic peptides, atrial natriuretic peptide, N-terminal pro-atrial natriuretic peptide, brain natriuretic peptide and its N-terminal moiety N-terminal pro-brain natriuretic peptide have also been found in critically ill patients. All of these peptides have been reported to reflect left ventricular dysfunction in these patients. The increased wall stress of the cardiac atria and ventricles is followed by the release of these natriuretic peptides. Furthermore, the release of atrial natriuretic peptide and brain natriuretic peptide might be triggered by members of the IL-6-related family and endotoxin in the critically ill. Apart from the vasoactive actions of circulating natriuretic peptides and their broad effects on the renal system, anti-ischemic properties and immunological functions have been reported for atrial natriuretic peptide. The early onset and rapid reversibility of left ventricular impairment in patients with good prognosis associated with a remarkably augmented plasma concentration of circulating natriuretic peptides suggest a possible role of these hormones in the monitoring of therapy success and the estimation of prognosis in the critically ill.

A retrospective cohort study of correlates of response to pharmacologic therapy for hyperlipidemia in members of a managed care organization

BACKGROUND

Few studies have examined the effectiveness of statins in a managed care setting.

OBJECTIVE

The aim of this study was to identify demographic, clinical, and pharmacotherapy-related factors associated with response to drug therapy for hyperlipidemia among members of a managed care organization.

METHODS

Claims data from a large US managed care organization from July 1, 1998, through June 30, 2000, were analyzed for adult members with continuous enrollment, >or=1 prescription drug claim, >or=2 sets of fasting low-density lipoprotein cholesterol (LDL-C) laboratory results, and no lipid-lowering prescription claims at any time <or=12 months before the date of the first set of LDL-C laboratory results. Relative lipid-lowering regimen efficacy categories were created based on percentage reduction in LDL-C listed in product package inserts (low, <or=30%; moderate, 31%-40%; high, >or=41%). Multiple regression and logistic regression models were developed to identify significant predictors of percentage change in LDL-C from baseline and of >or=10% reduction in LDL-C.

RESULTS

A total of 6247 members met the inclusion criteria. The mean (SD) age was 59.6 (12.4) years (range, 21-93 years), and 3003 individuals (48.1%) were women. Furthermore, 337 members (5.4%) received high-efficacy statins, 2633 (42.1%) received moderate-efficacy statins, 934 (15.0%) received low-efficacy statins, and 86 (1.4%) received low-efficacy lipid-lowering drugs from other therapeutic classes during the study period. Compliance with therapy was high (range, 85%-92%), and upward titration of therapy was found in only 160 members (2.6%). Multiple regression analysis indicated that receiving statin therapy compared with other lipid-lowering therapy was a significant predictor of percentage reduction in LDL-C (P < 0.001). Logistic regression analysis indicated that compared with high-efficacy statin regimens, low-efficacy statin regimens (odds ratio [OR] = 0.619; 95% CI, 0.436-0.877) and low-efficacy regimens from other therapeutic classes (OR = 0.171; 95% CI, 0.099-0.295) were less effective in lowering LDL-C by >or=10%. Similar results were observed for subanalyses of subjects with diabetes mellitus or coronary heart disease (CHD); individuals who received more efficacious statin regimens were more likely to reach the National Cholesterol Education Program Adult Treatment Panel II LDL-C goal of <or=100 mg/dL (P < 0.05 for moderate- or low-efficacy regimens vs high-efficacy statins in each model).

CONCLUSION

The results of the present study suggest that improvement is needed in hyperlipidemia management, especially in identification and use of lipid-lowering therapy in individuals at high risk for CHD.

B-Type Natriuretic Peptide and Its Clinical Implications in Heart Failure

B-type natriuretic peptide (BNP) is a cardiac neurohormone released as preproBNP and then enzymatically cleaved to N-terminal-proBNP and BNP upon ventricular myocyte stretch. Blood measurements of BNP have been used to identify patients with heart failure. Currently, BNP assay is used as a diagnostic and prognostic aid in congestive heart failure. In general, a BNP level <100 pg/mL excludes acutely decompensated heart failure. This article sorts out the literature concerning the practical use of BNP in a variety of clinical scenarios.