Use of Clinical and Echocardiographic Evaluation to Assess the Risk of Heart Failure

BACKGROUND

Clinical and echocardiographic features predict incident heart failure (HF), but the optimal strategy for combining them is unclear.

OBJECTIVES

This study sought to define an effective means of using echocardiography in HF risk evaluation.

METHODS

The same clinical and echocardiographic evaluation was obtained in 2 groups with HF risk factors: a training group (n = 926, followed to 7 years) and a validation group (n = 355, followed to 10 years). Clinical risk was categorized as low, intermediate, and high using 4-year ARIC (Atherosclerosis Risk In Communities) HF risk score cutpoints of 9% and 33%. A risk stratification algorithm based on clinical risk and echocardiographic markers of stage B HF (SBHF) (abnormal global longitudinal strain [GLS], diastolic dysfunction, or left ventricular hypertrophy) was developed using a classification and regression tree analysis and was validated.

RESULTS

HF developed in 12% of the training group, including 9%, 18%, and 73% of low-, intermediate-, and high-risk patients. HF occurred in 8.6% of stage A HF and 19.4% of SBHF (P < 0.001), but stage A HF with clinical risk of ≥9% had similar outcome to SBHF. Abnormal GLS (HR: 2.92 [95% CI: 1.95-4.37]; P < 0.001) was the strongest independent predictor of HF. Normal GLS and diastolic function reclassified 61% of the intermediate-risk group into the low-risk group (HF incidence: 12%). In the validation group, 11% developed HF over 4.5 years; 4%, 17%, and 39% of low-, intermediate-, and high-risk groups. Similar results were obtained after exclusion of patients with known coronary artery disease. The echocardiographic parameters also provided significant incremental value to the ARIC score in predicting new HF admission (C-statistic: 0.78 [95% CI: 0.71-0.84] vs 0.83 [95% CI: 0.77-0.88]; P = 0.027).

CONCLUSIONS

Clinical risk assessment is adequate to classify low and high HF risk. Echocardiographic evaluation reclassifies 61% of intermediate-risk patients.

Effectiveness of nurse-led multidisciplinary interventions in primary health care: A systematic review and meta-analysis

AIM

This review aimed to synthesize the available evidence on the effectiveness of nurse-led multidisciplinary interventions in primary health care.

METHODS

The following Chinese and English databases were searched for relevant articles: PubMed, Embase, Cochrane Library, Web of Science, China National Knowledge Infrastructure (CNKI), Wanfang and Chinese Biomedical Literature Database (CBM), from the establishment of the databases until the last updating search 1 April 2022. Two researchers screened the studies independently and extracted the data. Meta-analysis was performed using the RevMan 5.3 software.

RESULTS

A total of 12 studies were included in this review. It was found that nurse-led multidisciplinary interventions significantly shortened patients' length of stay in hospital (standardized mean differences [SMD] = -1.28, 95%CI: -2.03 to -0.54; P<0.001) and decreased incidences of complications (RR = 0.24, 95%CI:0.10 to 0.54; P = 0.0006) compared to the control group, and lowered patients' anxiety levels (SMD = -1.21, 95%CI: -1.99 to -0.44; P<0.01) and depression levels (SMD = -1.85, 95%CI: -3.42 to -0.28; P<0.0001). Furthermore, the results of subgroup analysis indicated that nurse-led multidisciplinary interventions had significant effects on patients' self-management ability (SMD = 4.45, 95%CI:2.45 to 6.44; P<0.0001) and quality of life (SMD = 1.01, 95%CI: 0.63 to 1.40; P<0.0001) compared to the control group.

CONCLUSIONS

Nurse-led multidisciplinary interventions had strong effects in primary health care, contributing to shorten patients' length of stay in hospital, decrease incidences of complications and reduce the levels of anxiety and depression. Moreover, nurse-led multidisciplinary interventions also improved patients' self-management ability and quality of life.

Person-Centered Models for Cardiovascular Care: A Review of the Evidence: A Scientific Statement From the American Heart Association

Cardiovascular disease remains the leading cause of death and disability in the United States and globally. Disease burden continues to escalate despite technological advances associated with improved life expectancy and quality of life. As a result, longer life is associated with multiple chronic cardiovascular conditions. Clinical guidelines provide recommendations without considering prevalent scenarios of multimorbidity and health system complexities that affect practical adoption. The diversity of personal preferences, cultures, and lifestyles that make up one's social and environmental context is often overlooked in ongoing care planning for symptom management and health behavior support, hindering adoption and compromising patient outcomes, particularly in groups at high risk. The purpose of this scientific statement was to describe the characteristics and reported outcomes in existing person-centered care delivery models for selected cardiovascular conditions. We conducted a scoping review using Ovid MEDLINE, Embase.com, Web of Science, CINAHL Complete, Cochrane Central Register of Controlled Trials through Ovid, and ClinicalTrials.gov from 2010 to 2022. A range of study designs with a defined aim to systematically evaluate care delivery models for selected cardiovascular conditions were included. Models were selected on the basis of their stated use of evidence-based guidelines, clinical decision support tools, systematic evaluation processes, and inclusion of the patient's perspective in defining the plan of care. Findings reflected variation in methodological approach, outcome measures, and care processes used across models. Evidence to support optimal care delivery models remains limited by inconsistencies in approach, variation in reimbursement, and inability of health systems to meet the needs of patients with chronic, complex cardiovascular conditions.

An inevitable or modifiable trajectory towards heart failure in high-risk individuals: insights from the nurse-led intervention for less chronic heart failure (NIL-CHF) study

AIMS

We extended follow-up of a heart failure (HF) prevention study to determine if initially positive findings of improved cardiac recovery were translated into less de novo HF and/or all-cause mortality (primary endpoint) in the longer term.

METHODS AND RESULTS

The Nurse-led Intervention for Less Chronic HF (NIL-CHF) study was a single-centre randomized trial of nurse-led prevention involving cardiac inpatients without HF. At 3 years, 454 survivors (aged 66 ± 11 years, 71% men and 68% coronary artery disease) had the following: (i) a normal echocardiogram (128 cases/28.2%), (ii) structural heart disease (196/43.2%), or (iii) left ventricular diastolic dysfunction/left ventricular systolic dysfunction (LVDD/LVSD: 130/28.6%). Outcomes were examined during median 8.3 (interquartile range 7.8-8.8) years according to these hierarchal groups and change in cardiac status from baseline to 3 years. Overall, 109 (24.0%) participants had a de novo HF admission or died while accumulating 551 cardiovascular-related admissions/3643 days of hospital stay. Progressively worse cardiac status correlated with increased hospitalizations (P < 0.001). The mean rate (95% confidence interval) of cardiovascular admissions/days of hospital stay being 0.09 (0.05-0.12) admissions/0.33 (0.13-0.54) days vs. 0.27 (0.20-0.34) admissions/2.20 (1.36-3.04) days per annum for those with a normal echocardiogram vs. LVDD/LVSD at 3 years. With progressively higher event rates, the adjusted hazard ratio for a de novo HF admission and/or death associated with a structural abnormality (24.5% of cases) and LVDD/LVSD (36.2%) at 3 years was 1.57 (0.82-3.01; P = 0.173) and 2.07 (1.05-4.05; P = 0.035) compared with a normal echocardiogram (10.9%). Mortality also mirrored the direction/extent of cardiac status/trajectory.

CONCLUSIONS

These data suggest the positive initial effects of NIL-CHF intervention on cardiac recovery contributed to better long-term outcomes among patients at high risk of HF. However, prevention of HF remains challenging.

Multicomponent integrated care for patients with chronic heart failure: systematic review and meta‐analysis

To investigate the effectiveness of multicomponent integrated care on clinical outcomes among patients with chronic heart failure. We conducted a meta-analysis of randomized clinical trials, published in English language from inception to 20 April 2022, with at least 3-month implementation of multicomponent integrated care (defined as two or more quality improvement strategies from different domains, viz. the healthcare system, healthcare providers, and patients). The study outcomes were mortality (all-cause or cardiovascular) and healthcare utilization (hospital readmission or emergency department visits). We pooled the risk ratio (RR) using Mantel-Haenszel test. A total of 105 trials (n = 37 607 patients with chronic heart failure; mean age 67.9 ± 7.3 years; median duration of intervention 12 months [interquartile range 6-12 months]) were analysed. Compared with usual care, multicomponent integrated care was associated with reduced risk for all-cause mortality [RR 0.90, 95% confidence interval (CI) 0.86-0.95], cardiovascular mortality (RR 0.73, 95% CI 0.60-0.88), all-cause hospital readmission (RR 0.95, 95% CI 0.91-1.00), heart failure-related hospital readmission (RR 0.84, 95% CI 0.79-0.89), and all-cause emergency department visits (RR 0.91, 95% CI 0.84-0.98). Heart failure-related mortality (RR 0.94, 95% CI 0.74-1.18) and cardiovascular-related hospital readmission (RR 0.90, 95% CI 0.79-1.03) were not significant. The top three quality improvement strategies for all-cause mortality were promotion of self-management (RR 0.86, 95% CI 0.79-0.93), facilitated patient-provider communication (RR 0.87, 95% CI 0.81-0.93), and e-health (RR 0.88, 95% CI 0.81-0.96). Multicomponent integrated care reduced risks for mortality (all-cause and cardiovascular related), hospital readmission (all-cause and heart failure related), and all-cause emergency department visits among patients with chronic heart failure.

Best Nursing Intervention Practices to Prevent Non-Communicable Disease: A Systematic Review

Objectives: To explore nursing health education interventions for non-communicable disease patients.

Methods: The design was a systematic review of research work published between 2008 and 2018. The data sources included the Web of Science, PubMed, Scopus, COCHRANE, and LILACS. The studies that met the inclusion were assessed, and the analysis for methodological quality through the recommended tools CASPe, and JADAD.

Results: Fifteen original studies from eight counties were included in the review; Findings revealed 13 studies with randomized samples and six used power analysis. Nurses’ interventions included house calls, home care, and individual and group health education.

Conclusion: Nursing interventions showed 76.4% the effectiveness of results in patient outcomes to promote and improve healthier lifestyles and quality of life of non-communicable disease patients. This review discloses the significant impact of nursing health education interventions. Nursing leadership and political decision-makers should consider providing programs to enhance health education knowledge and abilities. All of this can favor the sustainability of the global economy by changing the life style of thousands of people worldwide.

Systematic Review Registration:https://www.crd.york.ac.uk/prospero/, identifier CRD42020208809.

Prevention of Cardiovascular Diseases in Community Settings and Primary Health Care: A Pre-Implementation Contextual Analysis Using the Consolidated Framework for Implementation Research

Cardiovascular diseases are the world’s leading cause of mortality, with a high burden especially among vulnerable populations. Interventions for primary prevention need to be further implemented in community and primary health care settings. Context is critically important to understand potential implementation determinants. Therefore, we explored stakeholders’ views on the evidence-based SPICES program (EBSP); a multicomponent intervention for the primary prevention of cardiovascular disease, to inform its implementation. In this qualitative study, we conducted interviews and focus groups with 24 key stakeholders, 10 general practitioners, 9 practice nurses, and 13 lay community partners. We used adaptive framework analysis. The Consolidated Framework for Implementation Research guided our data collection, analysis, and reporting. The EBSP was valued as an opportunity to improve risk awareness and health behavior, especially in vulnerable populations. Its relative advantage, evidence-based design, adaptability to the needs and resources of target communities, and the alignment with policy evolutions and local mission and vision, were seen as important facilitators for its implementation. Concerns remain around legal and structural characteristics and intervention complexity. Our results highlight context dimensions that need to be considered and tailored to primary care and community needs and capacities when planning EBSP implementation in real life settings.

Clinical implications of the universal definition for the prevention and treatment of heart failure

The diagnosis of heart failure (HF) primarily relies on signs and symptoms that are neither sensitive nor specific. This impedes timely diagnosis and delays effective therapies or interventions, despite the availability of several evidence-based treatments for HF. Through monumental collaborative efforts from representatives of HF societies worldwide, the universal definition of HF was published in 2021, to provide the necessary standardized framework required for clinical management, clinical trials, and research. This review elaborates the key concepts of the new universal definition of HF, highlighting the key merits and potential avenues, which can be nuanced further in future iterations. We also discuss the key implications of the universal definition document from the perspectives of various stakeholders within the healthcare framework, including patients, care providers, system/payers and policymakers.

Comparison of Mortality and Hospital Readmissions Among Patients Receiving Virtual Ward Transitional Care vs Usual Postdischarge Care: A Systematic Review and Meta-analysis

IMPORTANCE

Virtual wards (VWs) include patient assessment in their homes by health care personnel and offer ongoing assessment and case management via home, telephone, and/or clinic visits. The association between VWs and patient outcomes during the transition from the hospital to home are unclear; earlier reviews on this topic have often conflated telemonitoring programs with VW models.

OBJECTIVE

To evaluate the use of VW transition systems for community-dwelling individuals after medical discharge.

DATA SOURCES

English-language articles indexed in PubMed or Cochrane and published between January 1, 2000, and June 15, 2021.

STUDY SELECTION

Randomized clinical trials comparing VW care with usual postdischarge care. Studies were stratified by diagnosis.

DATA EXTRACTION AND SYNTHESIS

Following the Preferred Reporting Items for Systematic Reviews and Meta-analyses guideline, 2 reviewers independently identified studies and extracted data. DerSimonian-Laird inverse variance weighted random-effects models were used to compute relative risks (RRs) for dichotomous outcomes and mean differences for continuous outcomes.

MAIN OUTCOMES AND MEASURES

All-cause mortality, hospital readmissions, emergency department visits, health care costs, readmission length of stay, quality of life, and functional status.

RESULTS

Twenty-four randomized clinical trials (11 in patients with heart failure, 3 in patients with chronic obstructive pulmonary disease, 4 in patients at high-risk for readmission, and 6 in mixed patient populations) with 10 876 patients were included (20 more trials than earlier reviews). In patients with heart failure, VWs were associated with fewer deaths (RR, 0.86; 95% CI, 0.76-0.97) and fewer readmissions (RR, 0.84; 95% CI, 0.74-0.96). However, similar associations were not seen in randomized clinical trials enrolling patients with other diagnoses (RR, 0.93; 95% CI, 0.83-1.04 for mortality and RR, 0.96; 95% CI, 0.88-1.05 for readmissions). Across all studies, VWs were associated with fewer emergency department visits (RR, 0.83; 95% CI, 0.70-0.98) and shorter readmission lengths of stay (mean difference, -1.94 days; 95% CI, -3.28 to -0.60 days). Three of 7 studies that evaluated health care expenses reported statistically significant lower costs with VW transition systems.

CONCLUSIONS AND RELEVANCE

Although postdischarge VW interventions appear to be associated with fewer subsequent emergency department visits, shorter readmission lengths of stay, and lower health care costs, fewer deaths and readmissions were seen only in trials enrolling patients with heart failure.

Incremental Value of Global Longitudinal Strain in the Long-Term Prediction of Heart Failure among Patients with Coronary Artery Disease

BACKGROUND

Heart failure (HF) remains a common complication for patients with coronary artery disease (CAD), especially after acute myocardial infarction. Although left ventricular ejection fraction (LVEF) is conventionally used to assess cardiac function for risk stratification, it has been shown in other settings to underestimate the risk of HF compared with global longitudinal strain (GLS). Moreover, most evidence pertains to early-onset HF. We sought the clinical and myocardial predictors for late-onset HF in patients with CAD.

METHODS

We analyzed echocardiograms (including GLS) in 334 patients with CAD (ages 65 ± 11 years, 77% male) who were enrolled in the Nurse-Led Intervention for Less Chronic Heart Failure trial, a prospective, randomized controlled trial that compared standard care with nurse-led intervention to prevent HF in individuals at risk of incident HF. Long-term (9 years) follow-up was obtained via data linkage. Analysis was performed using a competing-risk model.

RESULTS

Baseline LVEF values were normal or mildly impaired (LVEF ≥ 40%) in all subjects. After a median of 9 years of follow-up, 50 (15%) of the 334 patients had new HF admissions, and 68 (20%) died. In a competing-risk model, HF was associated with GLS (hazard ratio = 1.15 [1.05-1.25], P = .001), independent of estimated glomerular filtration rate (hazard ratio = 0.98 [0.97-0.99], P = .045), Charlson comorbidity score (hazard ratio = 1.64 [1.25-2.15], P < .001), or E/e' (hazard ratio = 1.08 [1.02-1.14], P = .01). Global longitudinal strain-but not conventional echocardiographic measures-added incremental value to a clinical model based on age, gender, and Charlson score (area under the curve, 0.78-0.83, P = .01). Global longitudinal strain was still associated with HF development in patients taking baseline angiotensin convertase enzyme inhibitors (hazard ratio = 1.21 [1.11-1.31], P < .01) and baseline beta-blockers (1.17 [1.09, 1.26]; P < .01). Mortality was associated with older men, risk factors (hypertension or diabetes), and comorbidities (AF and chronic kidney disease).

CONCLUSIONS

Global longitudinal strain is independently associated with risk of incident HF in patients admitted with CAD and provides incremental prognostic value to standard markers. Identifying an at-risk subgroup using GLS may be the focus of future randomized controlled trails to enable targeted therapeutic intervention.

The effect of nurse-led interventions on re-admission and mortality for congestive heart failure: A meta-analysis

BACKGROUND

The European Society of Cardiology guidelines recommend the implementation of nurse-led heart failure programs to achieve optimal management of patients with congestive heart failure (CHF). In this analysis, we aimed to systematically show the impact of nurse-led interventions (NLI) on re-admission and mortality in patients with CHF (reduced ejection fraction).

METHODS

Publications reporting the impact of NLI on readmission and mortality in patients with CHF were carefully searched from electronic databases. Rehospitalization and mortality were the endpoints. For this analysis, the latest version of the RevMan software was used. Risk ratios (RR) with 95% confidence intervals (CI) were used to represent data following analysis.

RESULTS

A total number of 3282 participants with CHF were included in this analysis. A total of 1571 patients were assigned to the nurse-led intervention group whereas 1711 patients were assigned to the usual care group. The patients had a mean age ranging from 50.8 to 80.3 years. Male patients varied from 27.3% to 73.8%. Comorbidities including hypertension (24.6%-80.0%) and diabetes mellitus (16.7%-59.7%) were also reported. Patients had a mean left ventricular ejection fraction varying from 29.0% to 61.0%. Results of this current analysis showed that rehospitalization (RR: 0.81, 95% CI: 0.74-0.88; P = .00001) and mortality (RR: 0.69, 95% CI: 0.56-0.86; P = .0009) were significantly lower among CHF patients who were assigned to the nurse-led intervention. Whether during a shorter (3-6 months) or a longer (1-2 years) follow up time period, rehospitalization for shorter [(RR: 0.73, 95% CI: 0.65-0.82; P = .00001) vs for longer (RR: 0.81, 95% CI: 0.72-0.91; P = .0003) respectively] and mortality for shorter [(RR: 0.55, 95% CI: 0.38-0.80; P = .002) vs longer follow up time period (RR: 0.76, 95% CI: 0.58-0.99; P = .04) respectively] were significantly lower and in favor of the nurse-led interventional compared to the normal care group.

CONCLUSIONS

This systematic review and meta-analysis of randomized controlled trials showed that NLI had significant impacts in reducing the risk of rehospitalization and mortality in these patients with CHF (reduced ejection fraction). Hence, we believe that nurse-led clinics and other interventional programs would be beneficial to patients with heart failure and this practice should, in the future be implemented to the health care system.

Multimorbidity and the Risk of All-Cause 30-Day Readmission in the Setting of Multidisciplinary Management of Chronic Heart Failure: A Retrospective Analysis of 830 Hospitalized Patients in Australia

BACKGROUND

Multimorbidity has an adverse effect on health outcomes in hospitalized individuals with chronic heart failure (CHF), but the modulating effect of multidisciplinary management is unknown.

OBJECTIVE

The aim of this study was to test the hypothesis that increasing morbidity would independently predict an increasing risk of 30-day readmission despite multidisciplinary management of CHF.

METHODS

We studied patients hospitalized for any reason with heart failure receiving nurse-led, postdischarge multidisciplinary management. We profiled a matrix of expected comorbidities involving the most common coexisting conditions associated with CHF and examined the relationship between multimorbidity and 30-day all-cause readmission.

RESULTS

A total of 830 patients (mean age 73 ± 13 years and 65% men) were assessed. Multimorbidity was common, with an average of 6.6 ± 2.4 comorbid conditions with sex-based differences in prevalence of 4 of 10 conditions. Within 30 days of initial hospitalization, 216 of 830 (26%) patients were readmitted for any reason. Greater multimorbidity was associated with increasing readmission (4%-44% for those with 0-1 to 8-9 morbid conditions; adjusted odds ratio, 1.25; 95% confidence interval, 1.13-1.38) for each additional condition. Three distinct classes of patient emerged: class 1-diabetes, metabolic, and mood disorders; class 2-renal impairment; and class 3-low with relatively fewer comorbid conditions. Classes 1 and 2 had higher 30-day readmission than class 3 did (adjusted P < .01 for both comparisons).

CONCLUSIONS

These data affirm that multimorbidity is common in adult CHF inpatients and in potentially distinct patterns linked to outcome. Overall, greater multimorbidity is associated with a higher risk of 30-day all-cause readmission despite high-quality multidisciplinary management. More innovative approaches to target-specific clusters of multimorbidity are required to improve health outcomes in affected individuals.

A Nurse-led Approach to Improving Cardiac Lifestyle Modification in an Atrial Fibrillation Population

Atrial fibrillation (AF) is a major public health problem and the most common cardiac arrhythmia encountered in clinical practice at this time. AF is associated with numerous symptoms such as palpitations, shortness of breath, and fatigue, which can significantly reduce health-related quality of life and result in serious adverse cardiac outcomes. In light of this, the aim of the present pilot study was to test the feasibility of implementing a mobile health (mHealth) lifestyle intervention titled "Atrial Fibrillation and Cardiac Health: Targeting Improving Outcomes via a Nurse-Led Intervention (ACTION)," with the goal of improving cardiac health measures, AF symptom recognition, and self-management. As part of this study, participants self-identified cardiac health goals at enrollment. The nurse used web-based resources from the American Heart Association (Dallas, TX, USA), which included the Life's Simple 7® My Life Check® assessment, to quantify current lifestyle behavior change needs. Furthermore, on the My AFib Experience™ website (American Heart Association, Dallas, TX, USA), the patient used a symptom tracker tool to capture the date, time, frequency, and type of AF symptoms, and these data were subsequently reviewed by the cardiac nurse. Throughout the six-month intervention period, the cardiac nurse used a motivational interviewing approach to support participants' cardiac health goals. Ultimately, the ACTION intervention was tested in 53 individuals with AF (mean age: 59 ± 11 years; 76% male). Participants were predominantly overweight/obese (79%), had a history of hypertension (62%) or hyperlipidemia (61%), and reported being physically inactive/not preforming any type of regular exercise (52%). The majority (88%) of the participants had one or more Life's Simple 7® measures that could be improved. Most of the participants (98%) liked having a dedicated nurse to work with them on a biweekly basis via the mHealth portal. The most commonly self-reported symptoms were palpitations, fatigue/exercise intolerance, and dyspnea. Seventy percent of the participants had an improvement in their weight and blood pressure as documented within the electronic health record as well as a corresponding improvement in their Life's Simple 7® score at six months. On average, there was a three-pound (1.36-kg) decrease in weight and a 5-mmHg decrease in systolic blood pressure between baseline and at six months. In conclusion, this pilot work provides initial evidence regarding the feasibility of implementing the ACTION intervention and supports testing the ACTION intervention in a larger cohort of AF patients to inform existing AF guidelines and build an evidence base for reducing AF burden through lifestyle modification.

Prevalence and profile of "seasonal frequent flyers" with chronic heart disease: Analysis of 1598 patients and 4588 patient-years follow-up

BACKGROUND

Peaks and troughs in cardiovascular events correlated with seasonal change is well established from an epidemiological perspective but not a clinical one.

METHODS

Retrospective analysis of the recruitment, baseline characteristics and outcomes during minimum 12-month exposure to all four seasons in 1598 disease-management trial patients hospitalised with chronic heart disease. Seasonality was prospectively defined as ≥4 hospitalisations (all-cause) AND >45% of related bed-days occurring in any one season during median 988 (IQR 653, 1394) days follow-up.

RESULTS

Patients (39% female) were aged 70 ± 12 years and had a combination of coronary artery disease (58%), heart failure (54%), atrial fibrillation (50%) and multimorbidity. Overall, 29.9% of patients displayed a pattern of seasonality. Independent correlates of seasonality were female gender (adjusted OR 1.27, 95% CI 1.01-1.61; p = 0.042), mild cognitive impairment (adjusted OR 1.51, 95% CI 1.16-1.97; p = 0.002), greater multimorbidity (OR 1.20, 95% CI 1.15-1.26 per Charlson Comorbidity Index Score; p < 0.001), higher systolic (OR 1.01, 95%CI 1.00-1.01 per 1 mmHg; p = 0.002) and lower diastolic (OR 0.99, 95% CI 0.98-1.00 per 1 mmHg; p = 0.002) blood pressure. These patients were more than two-fold more likely to die (adjusted HR 2.16, 95% CI 1.60-2.90; p < 0.001) with the highest and lowest number of deaths occurring during spring (31.7%) and summer (19.9%), respectively.

CONCLUSIONS

Despite high quality care and regardless of their diagnosis, we identified a significant proportion of "seasonal frequent flyers" with concurrent poor survival in this real-world cohort of patients with chronic heart disease.

Mild cognitive impairment is associated with subclinical diastolic dysfunction in patients with chronic heart disease

Background

To examine mild cognitive impairment and its associations with subclinical cardiac dysfunction in patients with chronic heart disease yet to develop the clinical syndrome of chronic heart failure (CHF).

Methods and results

Patients from the Nurse-led Intervention for Less Chronic Heart Failure Study (n = 373 with chronic heart disease other than CHF; 64 ± 11 years, 69% men) were screened for mild cognitive impairment [Montreal cognitive assessment (MoCA) score <26] and underwent echocardiographic/clinical profiling. We investigated associations of mild cognitive impairment and MoCA cognitive domain subscores with global cardiac status ('normal' vs. 'diastolic dysfunction' vs. 'other cardiac abnormality') and individual echocardiographic parameters. Patients with mild cognitive impairment (n = 161; 43%) demonstrated a higher age-adjusted prevalence of diastolic dysfunction (37% vs. 24%; P < 0.05). Multivariate logistic regression (adjusted for age, sex, and other relevant clinical factors) indicated that the odds of mild cognitive impairment were two-times higher with diastolic dysfunction (P = 0.030) and 1.7-times higher with 'other cardiac abnormalities' (P = 0.082) vs. normal cardiac status. In turn, mild cognitive impairment was predicted by left-ventricular (LV) filling pressure (based on the ratio of early diastolic filling and annular velocities; adjusted odds ratio 1.07 per unit increase, P = 0.022), but not LV structural parameters. Specific deficits in the cognitive domains of executive functioning and visuo-constructional abilities were also independently predicted by diastolic dysfunction (P < 0.05).

Conclusion

Mild cognitive impairment is prevalent in patients with subclinical chronic heart disease at high-risk of CHF. Independent associations with LV diastolic dysfunction suggest a link between cardiac and cognitive functioning beyond shared risk factors.

A multidisciplinary approach to prevention

Cardiovascular disease accounts for 17,500 deaths globally, representing nearly half of all non-communicable disease deaths. The World Health Organization has set nine lifestyle, risk factor and medicines targets to achieve by 2025 with the aim of reducing premature mortality from non-communicable diseases by 25%. In order to succeed in this, we need to equip our global health professional workforce with the skills to support patients and their families with making lifestyle changes and being in concordance with cardioprotective medication regimes at every opportunity. Success depends on collegiate working through effective interdisciplinary team-based care characterised by shared goals, clear roles, mutual trust, effective communication and measurable processes and outcomes, with the patient and family at the centre of care. Nurses are the largest sector of the health professional workforce and their role in prevention should be optimised. Nurse coordinated care is proven to be effective, especially where they work in an interdisciplinary way with other health professionals such as doctors, pharmacists and psychologists, who provide equally important expertise for supporting holistic care. Successful care models are those that comprehensively target all adverse lifestyles and risk factors that are responsible for the development of cardiovascular disease. These characteristics should be reflected in the standards and core components of prevention and rehabilitation programmes.

Economic evaluation of a nurse-led home and clinic-based secondary prevention programme to prevent progressive cardiac dysfunction in high-risk individuals: The Nurse-led Intervention for Less Chronic Heart Failure (NIL-CHF) randomized controlled study

OBJECTIVE

The objective of this study was to assess the cost-effectiveness of a long-term, nurse-led, multidisciplinary programme of home/clinic visits in preventing progressive cardiac dysfunction in patients at risk of developing de novo chronic heart failure (CHF).

METHODS

A trial-based analysis was conducted alongside a pragmatic, single-centre, open-label, randomized controlled trial of 611 patients (mean age: 66 years) with subclinical cardiovascular diseases (without CHF) discharged to home from an Australian tertiary referral hospital. A nurse-led home and clinic-based programme (NIL-CHF intervention, n = 301) was compared with standard care ( n=310) in terms of life-years, quality-adjusted life-years (QALYs) and healthcare costs. The uncertainty around the incremental cost and QALYs was quantified by bootstrap simulations and displayed on a cost-effectiveness plane.

RESULTS

During a median follow-up of 4.2 years, there were no significant between-group differences in life-years (-0.056, p=0.488) and QALYs (-0.072, p=0.399), which were lower in the NIL-CHF group. The NIL-CHF group had slightly lower all-cause hospitalization costs (AUD$2943 per person; p=0.219), cardiovascular-related hospitalization costs (AUD$1142; p=0.592) and a more pronounced reduction in emergency/unplanned hospitalization costs (AUD$4194 per person; p=0.024). When the cost of intervention was added to all-cause, cardiovascular and emergency-related readmissions, the reductions in the NIL-CHF group were AUD$2742 ( p=0.313), AUD$941 ( p=0.719) and AUD$3993 ( p=0.046), respectively. At a willingness-to-pay threshold of AUD$50,000/QALY, the probability of the NIL-CHF intervention being better-valued was 19%.

CONCLUSIONS

Compared with standard care, the NIL-CHF intervention was not a cost-effective strategy as life-years and QALYs were slightly lower in the NIL-CHF group. However, it was associated with modest reductions in emergency/unplanned readmission costs.

Lessons from contemporary trials of cardiovascular prevention and rehabilitation: A systematic review and meta-analysis

BACKGROUND

Meta-analyses of cardiac rehabilitation trials up to 2010 showed a significant reduction in all-cause mortality but many of these trials were conducted before the modern management of acute coronary syndromes.

METHODS

We undertook a meta-analysis of contemporary randomised controlled trials published in the period 2010 to 2015, including patients with other forms of atherosclerotic cardiovascular disease, to investigate the impact of cardiovascular prevention and rehabilitation on hard outcomes including survival.

RESULTS

18 trials randomising 7691 patients to cardiovascular prevention and rehabilitation or usual care were selected. All-cause mortality was not reduced (RR 1.00, 95% CI 0.88 to 1.14), but cardiovascular mortality was by 58% (95% CI 0.21, 0.88). Myocardial infarction was also reduced by 30% (95% CI 0.54, 0.91) and cerebrovascular events by 60% (95% CI 0.22, 0.74). Comprehensive programmes managing six or more risk factors reduced all-cause mortality in a subgroup analysis (RR 0.63, 95% CI 0.43, 0.93) but those managing less did not. In the three programmes that prescribed and monitored cardioprotective medications for blood pressure and lipids all-cause mortality was also reduced (RR 0.35, 95% CI 0.18, 0.70).

CONCLUSIONS

Comprehensive prevention and rehabilitation programmes managing six or more risk factors, and those prescribing and monitoring medications within programmes to lower blood pressure and lipids, continue to reduce all-cause mortality. In addition, these comprehensive programmes not only reduced cardiovascular mortality and myocardial infarction but also, for the first time, cerebrovascular events, and all these outcomes across a broader spectrum of patients with atherosclerotic disease.

Registry-Based Pragmatic Trials in Heart Failure: Current Experience and Future Directions

PURPOSE OF REVIEW

Randomized controlled trials (RCTs) in heart failure (HF) are becoming increasingly complex and expensive to conduct and if positive deliver expensive therapy tested only in selected populations.

RECENT FINDINGS

Electronic health records and clinical cardiovascular quality registries are providing opportunities for pragmatic and registry-based prospective randomized clinical trials (RRCTs). Simplified regulatory, ethics, and consent procedures; recruitment integrated into real-world care; and simplified or automated baseline and outcome collection allow assessment of study power and feasibility, fast and efficient recruitment, delivery of generalizable findings at low cost, and potentially evidence-based and novel use of generic drugs with low costs to society. There have been no RRCTs in HF to date. Major challenges include generating funding, international collaboration, and the monitoring of safety and adherence for chronic HF treatments. Here, we use the Spironolactone Initiation Registry Randomized Interventional Trial in Heart Failure with Preserved Ejection Fraction (SPIRRIT-HFpEF), to be conducted in the Swedish Heart Failure Registry, to exemplify the advantages and challenges of HF RRCTs.

Heart failure 2016: still more questions than answers

Heart failure has reached epidemic proportions given the ageing of populations and is associated with high mortality and re-hospitalization rates. This article reviews and summarizes recent advances in the diagnosis, assessment and treatment of the patients with heart failure. Data are discussed based also on the most recent guidelines indications. Open issues and unmet needs are highlighted.

Medical resource use and expenditure in patients with chronic heart failure: a population-based analysis of 88 195 patients

AIMS

Heart failure (HF) is one of the diseases with greater healthcare expenditure. However, little is known about the cost of HF at a population level. Hence, our aim was to study the population-level distribution and predictors of healthcare expenditure in patients with HF.

METHODS AND RESULTS

This was a population-based longitudinal study including all prevalent HF cases in Catalonia (Spain) on 31 December 2012 (n = 88 195). We evaluated 1-year healthcare resource use and expenditure using the Health Department (CatSalut) surveillance system that collects detailed information on healthcare usage for the entire population. Mean age was 77.4 (12) years; 55% were women. One-year mortality rate was 14%. All-cause emergency department visits and unplanned hospitalizations were required at least once in 53.4% and 30.8% of patients, respectively. During 2013, a total of €536.2 million were spent in the care of HF patients (7.1% of the total healthcare budget). The main source of expenditure was hospitalization (39% of the total) whereas outpatient care represented 20% of the total expenditure. In the general population, outpatient care and hospitalization were the main expenses. In multivariate analysis, younger age, higher presence of co-morbidities, and a recent HF or all-cause hospitalization were independently associated with higher healthcare expenditure.

CONCLUSIONS

In Catalonia, a large portion of the annual healthcare budget is devoted to HF patients. Unplanned hospitalization represents the main source of healthcare-related expenditure. The knowledge of how expenditure is distributed in a non-selected HF population might allow health providers to plan the distribution of resources in patients with HF.

Impact of Nurse-Led, Multidisciplinary Home-Based Intervention on Event-Free Survival Across the Spectrum of Chronic Heart Disease: Composite Analysis of Health Outcomes in 1226 Patients From 3 Randomized Trials

Background—

We sought to determine the overall impact of a nurse-led, multidisciplinary home-based intervention (HBI) adapted to hospitalized patients with chronic forms of heart disease of varying types.

Methods and Results—

Prospectively planned, combined, secondary analysis of 3 randomized trials (1226 patients) of HBI were compared with standard management. Hospitalized patients presenting with heart disease but not heart failure, atrial fibrillation but not heart failure, and heart failure, as well, were recruited. Overall, 612 and 614 patients, respectively, were allocated to a home visit 7 to 14 days postdischarge by a cardiac nurse with follow-up and multidisciplinary support according to clinical need or standard management. The primary outcome of days-alive and out-of-hospital was examined on an intention-to-treat basis. During 1371 days (interquartile range, 1112–1605) of follow-up, 218 patients died and 17 917 days of hospital stay were recorded. In comparison with standard management, HBI patients achieved significantly prolonged event-free survival (90.1% [95% confidence interval, 88.2–92.0] versus 87.2% [95% confidence interval, 85.1–89.3] days-alive and out-of-hospital; P=0.020). This reflected less all-cause mortality (adjusted hazard ratio, 0.67; 95% confidence interval, 0.50–0.88; P=0.005) and unplanned hospital stay (median, 0.22 [interquartile range, 0–1.3] versus 0.36 [0–2.1] days/100 days follow-up; P=0.011). Analyses of the differential impact of HBI on all-cause mortality showed significant interactions (characterized by U-shaped relationships) with age (P=0.005) and comorbidity (P=0.041); HBI was most effective for those aged 60 to 82 years (59%–65% of individual trial cohorts) and with a Charlson Comorbidity Index Score of 5 to 8 (36%–61%).

Conclusions—

These data provide further support for the application of postdischarge HBI across the full spectrum of patients being hospitalized for chronic forms of heart disease.

Clinical Trial Registration—

URL: http://www.anzctr.org.au. Unique identifiers: 12610000221055, 12608000022369, 12607000069459.

Cost-Effectiveness of a Home Based Intervention for Secondary Prevention of Readmission with Chronic Heart Disease

The aim of this study is to consider the cost-effectiveness of a nurse-led, home-based intervention (HBI) in cardiac patients with private health insurance compared to usual post-discharge care. A within trial analysis of the Young @ Heart multicentre, randomized controlled trial along with a micro-simulation decision analytical model was conducted to estimate the incremental costs and quality adjusted life years associated with the home based intervention compared to usual care. For the micro-simulation model, future costs, from the perspective of the funder, and effects are estimated over a twenty-year time horizon. An Incremental Cost-Effectiveness Ratio, along with Incremental Net Monetary Benefit, is evaluated using a willingness to pay threshold of $50,000 per quality adjusted life year. Sub-group analyses are conducted for men and women across three age groups separately. Costs and benefits that arise in the future are discounted at five percent per annum. Overall, home based intervention for secondary prevention in patients with chronic heart disease identified in the Australian private health care sector is not cost-effective. The estimated within trial incremental net monetary benefit is -$3,116 [95% CI: -11,145, $4,914]; indicating that the costs outweigh the benefits. However, for males and in particular males aged 75 years and above, home based intervention indicated a potential to reduce health care costs when compared to usual care (within trial: -$10,416 [95% CI: -$26,745, $5,913]; modelled analysis: -$1,980 [95% CI: -$22,843, $14,863]). This work provides a crucial impetus for future research to understand for whom disease management programs are likely to benefit most.

Overcoming the tyranny of distance: An analysis of outreach visits to optimise secondary prevention of cardiovascular disease in high-risk individuals living in Central Australia

OBJECTIVES

We examined the logistical challenges of conducting an outreach, secondary prevention program for adults discharged from Alice Springs Hospital following an acute presentation of cardiovascular disease.

DESIGN AND SETTING

This represents a sub-study of the Central Australian Heart Protection Study (CAHPS). Clinical, logistic and demographic data were used to examine the characteristics of outreach visits in the intervention arm of the study.

PARTICIPANTS

Fifty subjects initially allocated to the intervention arm of the trial were studied.

MAIN OUTCOME MEASURES

Completion of scheduled, plus additional outreach visits according to the intervention protocol.

RESULTS

The majority of subjects presented with an acute coronary syndrome (44/50 (88%)) and 31 (62%) were of Indigenous ethnicity. However, Indigenous subjects being younger (53.1 ± 11.1 versus 58.0 ± 11.0 years non-Indigenous) had a more complex risk factor and co-morbid profile, with significantly more diabetes (77% versus 26% P < 0.001), hypertension (81% versus 53% P = 0.04) and renal failure (52% versus 21% P = 0.03). Community of origin of Indigenous subjects was 230 ± 208 km from the hospital versus 61 ± 150 km for non-Indigenous subjects (P = 0.004). Indigenous subjects missed a significantly higher number of scheduled visits at six months (1.39 ± 2.14 versus 0.16 ± 0.50 visits; P = 0.02). However, multivariate analyses suggested that distance did not influence successful completion of visits.

CONCLUSIONS

These early findings from CAHPS are invaluable to understanding and improving the feasibility of secondary prevention programs for Indigenous adults living with heart disease in remote communities.