Nutritional Interventions in Heart Failure: A Systematic Review of the Literature

Low Prognostic Nutritional Index Predicts Adverse Outcomes in Patients With Heart Failure: A Systematic Review and Meta-analysis

The association of low prognostic nutritional index (PNI) with adverse outcomes remains conflicting in heart failure patients. To address these knowledge gaps, we performed this meta-analysis to investigate the predictive value of PNI in patients with heart failure (HF). PubMed and Embase databases were comprehensively searched until January 19, 2023, to identify studies that evaluated the predictive role of PNI in HF patients. Outcomes of interest included all-cause mortality and/or combined endpoint of mortality and re-hospitalization. Twelve studies involving 9365 patients with HF were included and analyzed. Comparison of the lowest with the highest PNI, the pooled multivariate adjusted risk ratio (RR) was 1.79 (95% confidence interval [CI] 1.40-2.30) and 2.67 (95% CI 1.92-3.71) for long-term all-cause mortality and combined endpoint of mortality and re-hospitalization, respectively. Furthermore, per unit reduction in PNI was associated with 8% higher risk of all-cause mortality. However, there was no clear association of low PNI with in-hospital mortality. Low PNI may be an independent predictor of long-term all-cause mortality and re-hospitalization in patients with HF. Estimation of nutritional state using the PNI may provide an important clue for risk stratification in these patients.

Impact of nurse-led education on the prognosis of heart failure patients: A systematic review and meta-analysis

AIM

To perform a meta-analysis of randomized controlled trials to investigate the effect of nurse-led education on death, readmission, and quality of life in patients with heart failure.

BACKGROUND

The evidence of the effectiveness of nurse-led education in heart failure patients from randomized controlled trials is limited, and the results are inconsistent. Therefore, the impact of nurse-led education remains poorly understood, and more rigorous studies are needed.

INTRODUCTION

Heart failure is a syndrome associated with high morbidity, mortality, and hospital readmission. Authorities advocate nurse-led education to raise awareness of disease progression and treatment planning, as this could improve patients' prognosis.

METHODS

PubMed, Embase, and the Cochrane Library were searched up to May 2022 to retrieve relevant studies. The primary outcomes were readmission rate (all-cause or HF-related) and all-cause mortality. The secondary outcome was quality of life, evaluated by the Minnesota Living with Heart Failure Questionnaire (MLHFQ), EuroQol-5D (EQ-5D), and visual analog scale for quality of life.

RESULTS

Although there was no significant association between the nursing intervention and all-cause readmissions [RR (95% CI) = 0.91 (0.79, 1.06), P = 0.231], the nursing intervention decreased HF-related readmission by 25% [RR (95% CI) = 0.75 (0.58, 0.99), P = 0.039]. The e nursing intervention reduced all-cause readmission or mortality as a composite endpoint by 13% [RR (95% CI) = 0.87 (0.76, 0.99), P = 0.029]. In the subgroup analysis, we found that home nursing visits reduced HF-related readmissions [RR (95% CI) = 0.56 (0.37, 0.84), P = 0.005]. In addition, the nursing intervention improved the quality of life in MLHFQ and EQ-5D [standardized mean differences (SMD) (95% CI) = 3.38 (1.10, 5.66), 7.12 (2.54, 11.71), respectively].

DISCUSSION

The outcome variation between studies may be due to reporting methods, comorbidities, and medication management education. Patient outcomes and quality of life may also vary between different educational approaches. Limitations of this meta-analysis stem from the incomplete reporting of information from the original studies, the small sample size, and the inclusion of English language literature only.

CONCLUSION

Nurse-led education programs significantly impact HF-related readmission rates, all-cause readmission, and mortality rates in patients with HF.

IMPLICATIONS FOR NURSING PRACTICE AND NURSING POLICIES

The results suggest stakeholders should allocate resources to develop nurse-led education programs for HF patients.

Omega-3 supplementation and outcomes of heart failure: A systematic review of clinical trials

BACKGROUNDS

Omega-3 supplements are endorsed for heart failure (HF) patients to reduce hospitalizations and mortality, offering anti-inflammatory and cardioprotective benefits.

METHODS

A comprehensive search was conducted in various databases until November 2022. Eligible studies included clinical trials on patients with HF. Data extraction covered study details, omega-3 specifics, outcomes, and limitations. The JADAD scale was used to assess the risk of bias in randomized controlled trials.

RESULTS

The review process involved 572 records from database searches, resulting in 19 studies after eliminating duplicates and screening. These studies assessed the impact of omega-3 on various clinical outcomes, such as mortality, hospitalization, cardiac function, and quality of life. Studied duration varied from weeks to years. Omega-3 supplementation demonstrated potential benefits such as improved heart function, reduced inflammation, and decreased risk of cardiovascular events.

CONCLUSION

Omega-3 supplementation could benefit heart disease treatment, potentially reducing therapy duration and improving outcomes. Starting omega-3 supplementation for HF patients seems favorable.

What are the outcomes of dietary interventions in Heart Failure with preserved Ejection Fraction? A systematic review and meta-analysis

AIMS

To determine the efficacy of dietary interventions in Heart Failure with preserved Ejection Fraction (HFpEF).

METHOD AND RESULTS

Keyword searches were performed in five bibliographic databases to identify randomized or controlled studies of dietary interventions conducted in HFpEF or mixed heart failure (HF) samples published in the English language. Studies were appraised for bias and synthesized into seven categories based on the similarity of the intervention or targeted population. The quality of the body of evidence was assessed via the GRADE (Grading of Recommendations, Assessment, Development, and Evaluations) framework. Twenty-five unique interventions were identified; 17 were considered for meta-analysis. Most studies were judged to be at high risk of bias. There was moderate-quality evidence that caloric restriction led to clinically meaningful improvements in blood pressure and body weight. There was moderate-quality evidence that carbohydrate restriction resulted in meaningful reductions in blood pressure. There was very low-quality evidence that protein supplementation improved blood pressure and body weight and moderate-quality evidence for clinically meaningful improvements in function.

CONCLUSIONS

While some types of dietary interventions appeared to deliver clinically meaningful change in critical outcomes; the study heterogeneity and overall quality of the evidence make it difficult to make firm recommendations. Greater transparency when reporting the nutritional composition of interventions would enhance the ability to pool studies.

REGISTRATION

PROSPERO CRD42019145388.

Heart failure symptom burden, dietary intake, and inflammation: An integrative review of the literature

Heart failure (HF) is characterized by high symptom burden including, but not limited to fatigue, dyspnea, and edema. Up to 21.5% of HF patients experience significant depressive symptoms, much higher than 7.1% in adults without HF. Diet, metabolites, and other inflammatory mechanisms have gained notable attention in recent studies for contributions to symptoms in HF. Symptoms for black adults (B/As) with HF are often influenced by lifestyle factors, which may influence their higher mortality rates; few studies address these factors. Distinguishing the links between key elements with diet, inflammation, and symptoms may bring clarity for new dietary strategies in HF clinical care. The purpose of this integrative review is to examine the existing literature regarding relationships among physiologic pathways in HF along with physical and emotional symptoms in the context of inflammation, dietary intake, tumor necrosis factor-alpha (TNF-α), a biomarker of inflammation, and trimethylamine-N-Oxide (TMAO). Based on available evidence, inflammation may be a key link between physical symptoms, diet, depression, TMAO, and TNF-α in persons with HF and warrants further examination to clarify pathological links to solidify evidence for better guidance with dietary modifications. The literature reviewed in this study demonstrates that more work is needed to examine dietary planning, social support, and differences between men and women in the B/A community. Results of this literature review call attention to the essential, personalized care needs related to symptom monitoring and dietary planning which is expected to decrease symptom burden in the HF population.

What dietary interventions have been tested in heart failure with preserved ejection fraction? A systematic scoping review

AIMS

To determine what dietary interventions have been tested in heart failure with preserved ejection fraction (HFpEF), the modulation method, and outcomes employed and to summarize any evidence for benefit.

METHODS AND RESULTS

We performed key word searches in five bibliographic databases from 2001 to 2021, to identify randomized or experimental dietary interventions tested in HFpEF or mixed heart failure (HF) samples. Study characteristics were summarized according to population, intervention, comparator, outcome categories and intervention complexity was assessed. Twenty-five clinical investigations were retrieved; only 10 (40%) were conducted exclusively in HFpEF; the remainder enrolled mixed HF samples. Most studies employed either highly tailored prescribed diets (n = 12, 48%) or dietary supplementation (n = 10, 40%) modalities. Dietary pattern interventions (n = 3, 12%) are less well represented in the literature.

CONCLUSION

Heterogeneity made pooling studies challenging. Better reporting of baseline characteristics and the use of standardized HF lexicon would ensure greater confidence in interpretation of studies involving mixed HF populations. The field would benefit greatly from explicit reporting of the biological mechanism of action (e.g. the causal pathway) that an intervention is designed to modulate so that studies can be synthesized via their underlying mechanism of action by which diet may affect HF. An extension of the current set of core outcomes proposed by the European Society of Cardiology Heart Failure Association would ensure dietary clinical endpoints are more consistently defined and measured.

REGISTRATION

PROSPERO: CRD42019145388.

Confidence in self-care after heart failure hospitalization

BACKGROUND

Understanding patient perspectives of self-care is critical for improving multidisciplinary education programs and adherence to such programs. However, perspectives of self-care for patients with heart failure (HF) as well as the association between patient perspectives and patient-physician communication remain unclear.

METHODS

Confidence levels regarding self-care behaviors (eight lifestyle behaviors and four consulting behaviors) and self-monitoring were assessed using a self-administered questionnaire survey, which was directly distributed by dedicated physicians and nurses to consecutive patients hospitalized with HF in a tertiary-level hospital. Patient-physician communication was evaluated according to the quality of physician-provided information regarding "treatment and treatment choices" and "prognosis" using the Prognosis and Treatment Perception Questionnaire. Out of 202 patients, 187 (92.6 %) agreed to participate, and 176 completed the survey [valid response rate, 87.1 %; male, 67.0 %; median age, 73 (63-81) years]. Multivariate logistic regression analyses were conducted to predict low confidence in self-care (score in the lowest quartile).

RESULTS

High confidence (confident or completely confident >75 % of patients) was observed for all self-care behavior categories except low-salt diet (63.1 %), regular exercise (63.1 %), and flu vaccination (65.9 %). Lower confidence in self-care behavior was associated with low quality of patient-physician communication. With regard to self-monitoring, 62.5 % of patients were not confident in distinguishing worsening symptoms of HF from other diseases; non-confidence was also associated with low quality of patient-physician communication.

CONCLUSIONS

Hospitalized patients with HF had low confidence regarding regular exercise, salt restriction, and flu vaccination. The results also suggest patient-physician communication affects patient confidence.

High Exogenous Antioxidant, Restorative Treatment (Heart) for Prevention of the Six Stages of Heart Failure: The Heart Diet

The exact pathophysiology of heart failure (HF) is not yet known. Western diet, characterized by highly sweetened foods, as well as being rich in fat, fried foods, red meat and processed meat, eggs, and sweet beverages, may cause inflammation, leading to oxidative dysfunction in the cardiac ultra-structure. Oxidative function of the myocardium and how oxidative dysfunction causes physio-pathological remodeling, leading to HF, is not well known. Antioxidants, such as polyphenolics and flavonoids, omega-3 fatty acids, and other micronutrients that are rich in Indo-Mediterranean-type diets, could be protective in sustaining the oxidative functions of the heart. The cardiomyocytes use glucose and fatty acids for the physiological functions depending upon the metabolic requirements of the heart. Apart from toxicity due to glucose, lipotoxicity also adversely affects the cardiomyocytes, which worsen in the presence of deficiency of endogenous antioxidants and deficiency of exogenous antioxidant nutrients in the diet. The high-sugar-and-high-fat-induced production of ceramide, advanced glycation end products (AGE) and triamino-methyl-N-oxide (TMAO) can predispose individuals to oxidative dysfunction and Ca-overloading. The alteration in the biology may start with normal cardiac cell remodeling to biological remodeling due to inflammation. An increase in the fat content of a diet in combination with inducible nitric oxide synthase (NOSi) via N-arginine methyl ester has been found to preserve the ejection fraction in HF. It is proposed that a greater intake of high exogenous antioxidant restorative treatment (HEART) diet, polyphenolics and flavonoids, as well as cessation of red meat intake and egg, can cause improvement in the oxidative function of the heart, by inhibiting oxidative damage to lipids, proteins and DNA in the cell, resulting in beneficial effects in the early stage of the Six Stages of HF. There is an unmet need to conduct cohort studies and randomized, controlled studies to demonstrate the role of the HEART diet in the treatment of HF.

Registered Dietitian Nutritionists' Role in Hospital in Home

BACKGROUND

Hospital in Home (HIH) involves the delivery of acute care services in a patient's home. There is currently a paucity of published information regarding nutrition care in HIH.

OBSERVATIONS

The registered dietitian nutritionist (RDN) contributes to HIH by providing personalized medical nutrition therapy and collaborating with the HIH interdisciplinary team for optimal health care delivery. Tips for utilizing RDN services are also discussed.

CONCLUSIONS

As HIH becomes more widely adopted within the Veterans Health Administration and other health care systems, it is crucial to consider the value and expertise of the RDN for guiding nutrition care in the HIH setting.

Identify Early and Involve Everyone: Interdisciplinary Comprehensive Care Pathway Developed for Inpatient Management and Transitions of Care for Heart Failure Patients Reported Using SQUIRE 2.0 Guidelines

Introduction

Heart failure accounts for 1-2% of overall healthcare costs. While the link between re-hospitalization and mortality is unclear, care pathways that standardize inpatient management and establish outpatient follow-up improve patient outcomes and reduce morbidity.

Aim

To implement a comprehensive interdisciplinary care pathway for heart failure patients with the goal of optimizing inpatient management and improving transitions of care.

Methods

To address this clinical need, New York-Presbyterian Brooklyn Methodist Hospital (NYP-BMH) identified resources needed to optimize patient care, developed an inpatient admission order set (so-called “power plan”), and implemented a multidisciplinary clinical care pathway. The Plan-Do-Study-Act cycle addressed the implementation obstacles. Interdisciplinary rounds guided day-to-day management and addressed barriers. Our team developed a sustainable care pathway, and measured the utilization of pharmacy, nutrition, physical therapy, case management, and social work resources; outpatient appointments were made prior to discharge. We used the Standards for Quality Improvement Reporting Excellence (SQUIRE) 2.0 guidelines to guide our planning and evaluation of this quality improvement initiative.

Results

Our intervention markedly increased the number of heart failure hospitalizations that were identified on admission, and the use of pharmacy/nutrition services was greater after the intervention. The utilization of our “power plan” promoted adherence to a series of evidence-based best practices, but these measures had no significant impact on readmissions as a whole. The involvement of the case management support team increased outpatient appointments made for patients prior to discharge and aided in the transition of care from inpatient to outpatient management.

Conclusion

The management of heart failure patients starts in the hospital and continues in the community. Patients who are treated in a standardized dedicated care pathway have reduced morbidity and better outcomes. Identifying these patients early, involving a comprehensive team, and transitioning their care to the outpatient setting improves the quality of care in these patients.

Predictors of completion and response to a psychological intervention to promote health behavior adherence in heart failure

OBJECTIVE

Most individuals with heart failure (HF) struggle to adhere to one or more health behaviors, and interventions to promote adherence are time-intensive and costly. In this analysis, we examined the predictors of engagement and response related to a telephone-delivered health behavior intervention for individuals with HF.

METHOD

Using data from two pilot trials (N = 25) of a behavioral intervention for individuals with New York Heart Association (NYHA) class I-II HF, we examined predictors of intervention engagement and response using linear and mixed effects regression analyses. Predictors included medical (NYHA class, physical health-related quality of life [HRQoL], and HF symptoms) and intervention (ease and usefulness/utility ratings of the first intervention exercise) characteristics. Outcomes included percentage of sessions completed, accelerometer-measured physical activity, and sodium intake.

RESULTS

Lower physical HRQoL and more frequent HF symptoms were associated with completion of more sessions. In contrast, more frequent HF symptoms and higher NYHA class were associated with less physical activity improvement. Finally, participants' ratings of the first session's utility were associated with greater improvements in physical activity at follow-up.

CONCLUSIONS

These findings suggest that while individuals with greater functional impairment are more engaged in a behavioral intervention, they may be less able to increase physical activity in response to the program. Furthermore, the perceived utility of an initial session may predict longer-term behavior change. Larger studies are needed to clarify the presence of additional predictors and determine how they can be used to better tailor health behavior interventions.

Dietary Management of Heart Failure: DASH Diet and Precision Nutrition Perspectives

Heart failure (HF) is a major health care burden increasing in prevalence over time. Effective, evidence-based interventions for HF prevention and management are needed to improve patient longevity, symptom control, and quality of life. Dietary Approaches to Stop Hypertension (DASH) diet interventions can have a positive impact for HF patients. However, the absence of a consensus for comprehensive dietary guidelines and for pragmatic evidence limits the ability of health care providers to implement clinical recommendations. The refinement of medical nutrition therapy through precision nutrition approaches has the potential to reduce the burden of HF, improve clinical care, and meet the needs of diverse patients. The aim of this review is to summarize current evidence related to HF dietary recommendations including DASH diet nutritional interventions and to develop initial recommendations for DASH diet implementation in outpatient HF management. Articles involving human studies were obtained using the following search terms: Dietary Approaches to Stop Hypertension (DASH diet), diet pattern, diet, metabolism, and heart failure. Only full-text articles written in English were included in this review. As DASH nutritional interventions have been proposed, limitations of these studies are the small sample size and non-randomization of interventions, leading to less reliable evidence. Randomized controlled interventions are needed to offer definitive evidence related to the use of the DASH diet in HF management.

Effects of Bergamot Polyphenols on Mitochondrial Dysfunction and Sarcoplasmic Reticulum Stress in Diabetic Cardiomyopathy

Cardiovascular disease is the leading cause of death and disability in the Western world. In order to safeguard the structure and the functionality of the myocardium, it is extremely important to adequately support the cardiomyocytes. Two cellular organelles of cardiomyocytes are essential for cell survival and to ensure proper functioning of the myocardium: mitochondria and the sarcoplasmic reticulum. Mitochondria are responsible for the energy metabolism of the myocardium, and regulate the processes that can lead to cell death. The sarcoplasmic reticulum preserves the physiological concentration of the calcium ion, and triggers processes to protect the structural and functional integrity of the proteins. The alterations of these organelles can damage myocardial functioning. A proper nutritional balance regarding the intake of macronutrients and micronutrients leads to a significant improvement in the symptoms and consequences of heart disease. In particular, the Mediterranean diet, characterized by a high consumption of plant-based foods, small quantities of red meat, and high quantities of olive oil, reduces and improves the pathological condition of patients with heart failure. In addition, nutritional support and nutraceutical supplementation in patients who develop heart failure can contribute to the protection of the failing myocardium. Since polyphenols have numerous beneficial properties, including anti-inflammatory and antioxidant properties, this review gathers what is known about the beneficial effects of polyphenol-rich bergamot fruit on the cardiovascular system. In particular, the role of bergamot polyphenols in mitochondrial and sarcoplasmic dysfunctions in diabetic cardiomyopathy is reported.

Effects of aerobic and resistance exercise training associated with carnosine precursor supplementation on maximal strength and V̇O2max in rats with heart failure

BACKGROUND

Combined exercise training (CET) has been associated with positive responses in the clinical status of patients with heart failure (HF). Other nonpharmacological tools, such as amino acid supplementation, may further enhance its adaptation. The aim was to test whether CET associated with supplementing carnosine precursors could present better responses in the functional capacity and biochemical variables of rats with HF.

METHODS

Twenty-one male Wistar rats were subjected to myocardial infarction and allocated to three groups: sedentary (SED, n = 7), CET supplemented with placebo (CETP, n = 7), and CET with HF supplemented with β-alanine and L-histidine (CETS, n = 7). The trained animals were submitted to a strength protocol three times per week. Aerobic training was conducted twice per week. The supplemented group received β-alanine and L-histidine orally (250 mg/kg per day).

RESULTS

Maximum oxygen uptake, running distance, time to exhaustion and maximum strength were higher in the CET-P group than that in the SED group and even higher in the CET-S group than that in the CET-P group (P < 0.01). CET-S showed lower oxidative stress and inflammation markers and higher heat shock protein 72 kDa content and mRNA expression for calcium transporters in the skeletal muscle compared to SED.

CONCLUSION

CET together with β-alanine and L-histidine supplementation in rats with HF can elicit adaptations in both maximum oxygen uptake, running distance, time to exhaustion, maximum strength, oxidative stress, inflammation and mRNA expression. Carnosine may influence beneficial adjustments in the cell stress response in the skeletal muscle and upregulate the mRNA expression of calcium transporters.

Dietary diversity and food security status among heart failure patients in the north of Iran

Background

Dietary diversity score (DDS) is an indicator for assessing nutritional adequacy. Food security is another important measure in nutrition field which can be associated with several cardiovascular risk factors. Considering the importance of nutrition in heart failure (HF) patients, this study was designed to evaluate the DDS and food security of patients with HF.

Methods

A total of 200 HF patients were enrolled. DDS was evaluated using valid and reliable food frequency questionnaire and was calculated by scoring food intakes as 5 main groups. Household food insecurity access scale was applied to assess food security status. Data were analyzed using descriptive statistics, Chi-square and Kruskal-Wallis tests and multiple logistic regression models.

Results

The mean age of patients was 65 (standard deviation: 12) years and 59% of patients were male. Median of DDS was 1.96 (range: 0.29 to 6.12). Adjusted odds of greater DDS (> = median of 2) was 2.58 times higher for patients without hypertension than for patients with hypertension (95%CI: 1.31–5.08, P = 0.006). Also, odds of greater DDS were more in ex-smokers’ patients when compared to non-smokers (adjusted odds ratio (AOR): 2.70, 95%CI: 1.27–5.75, P = 0.010), patients with supplement use (AOR: 2.42, 95%CI: 1.16–5.05, P = 0.019), patients with lower total cholesterol level (AOR: 1.01, 95%CI: 1.00–1.02, P = 0.051), and patients with higher ejection fraction (AOR: 1.03, 95%CI: 1.00–1.05, with borderline.

P = 0.073). About 57% of patients had experienced degrees of food insecurity as mild (26%), moderate (16%) and severe (15%). On the other hand, women (AOR: 1.90, 95%CI: 0.90–3.71, with borderline P = 0.061) and patients with middle (AOR: 3.48, 95%CI: 1.79–6.76, P < 0.001) or high (AOR: 20.32, 95%CI: 2.56–161.19, P = 0.004) socio-economic status were more likely to be food secure or mild insecure. Also, no relation between DDS and food security was found (r = − 0.08, P = 0.262).

Conclusion

This study found that HF patients had a low DDS and more than half of the patients were food insecure to some extents.

Health schools as an organizational form of realization of the "life course health development" concept

This study was conducted to evaluate the effectiveness of health education in the Tatarstan Republic by establishing educational programs - Health Schools - for groups of patients with a high risk of developing potentially fatal cardiac and respiratory conditions. The concept of "Life Course Health Development" implies the development of mechanisms for personalized health management. The goal of the study is to explore the effectiveness of the specialized Health Schools in Tatarstan. For the comparative study of health education effects on the overall state of personal health, 590 patients were surveyed in a randomized controlled trial. The groups of patients were compared in relation to their health education; their health status was observed prior to and afterward undergoing the educative preventative programs and estimated in comparison between the two groups. Extrapolation of the data on Tatarstan's patient population was obtained through this study, taking into account the state of health of the Health Schools students, obtaining the regression equations of population mortality and the effects of training on it. The effectiveness of Health Schools for patients with cardiovascular pathology has been proven. However, additional efforts are required to involve a wider range of patients and increase learning effectiveness to critical levels of awareness by introducing new forms of education in Health Schools since it statistically significantly increased the awareness level regarding disease nature and preventive measures.

Individualized Nutritional Support for Hospitalized Patients With Chronic Heart Failure

BACKGROUND

Deterioration of nutritional status during hospitalization in patients with chronic heart failure increases mortality. Whether nutritional support during hospitalization reduces these risks, or on the contrary, may be harmful due to an increase in salt and fluid intake, remains unclear.

OBJECTIVES

The purpose of this trial was to study the effect of nutritional support on mortality in patients hospitalized with chronic heart failure who are at nutritional risk.

METHODS

A total of 645 patients with chronic heart failure (36% [n = 234] with acute decompensation) participated in the investigator-initiated, open-label EFFORT (Effect of early nutritional support on Frailty, Functional Outcomes and Recovery of malnourished medical inpatients) trial. Patients were randomized to protocol-guided individualized nutritional support to reach energy, protein, and micronutrient goals (intervention group) or standard hospital food (control group). The primary endpoint was all-cause mortality at 30 days.

RESULTS

Mortality over 180 days increased with higher severity of malnutrition (odds ratio per 1-point increase in Nutritional Risk Screening 2002 score: 1.65; 95% confidence interval [CI]: 1.21 to 2.24; p = 0.001). By 30 days, 27 of 321 intervention group patients (8.4%) died, compared with 48 of 324 (14.8%) control group patients (odds ratio: 0.44; 95% CI: 0.26 to 0.75; p = 0.002). Patients at high nutritional risk showed the most benefit from nutritional support. Mortality effects remained significant at 180-day follow-up. Intervention group patients also had a lower risk for major cardiovascular events at 30 days (17.4% vs. 26.9%; odds ratio: 0.50; 95% CI: 0.34 to 0.75; p = 0.001).

CONCLUSIONS

Among hospitalized patients with chronic heart failure at high nutritional risk, individualized nutritional support reduced the risk for mortality and major cardiovascular events compared with standard hospital food. These data support malnutrition screening upon hospital admission followed by an individualized nutritional support strategy in this vulnerable patient population. (Effect of Early Nutritional Therapy on Frailty, Functional Outcomes and Recovery of Undernourished Medical Inpatients Trial [EFFORT]; NCT02517476).

Comparison of learning needs priorities between healthcare providers and patients with heart failure

It is necessary to understand the learning needs of heart failure (HF) patients to provide adequate patient education. It is necessary to identify what HF patients want to know and how this differs from the educational needs of healthcare providers. The aim of this descriptive and exploratory study was to evaluate and compare the learning needs priorities between HF patients and their healthcare providers. One hundred patients with HF and 20 healthcare providers were recruited from cardiovascular outpatient clinics at 2 large tertiary medical centers in South Korea. Learning needs were measured using a self-administered questionnaire with the Heart Failure Patients’ Learning Needs Inventory. Data were analyzed using SPSS 23.0 program. Overall rank orders for 48 items were similar in both groups (Spearman rank order correlation 0.605, p < .001). The educational topics of medications and worsening signs and symptoms ranked highest in both groups. However, healthcare providers were more concerned with diet management than were the patients (mean score 4.18 vs. 3.62; p = .001). The study showed both similarities and differences between the assessments of the patients and healthcare providers of detailed educational learning needs. It is important to develop patient-centered educational materials considering HF patients’ actual learning needs, and also to provide comprehensive and practical patient education based on a supportive understanding of healthcare provider needs.

Caloric restriction in heart failure: A systematic review

BACKGROUND AND AIMS

Nutrition exerts a determinant role in maintaining cardiac function, regulating insulin and mitochondrial efficiency, that are essential to support energy production for contractility. In patients with heart failure (HF), myocardial tissue efficiency is reduced because of decreased mitochondrial oxidative capacity. In HF conditions, cardiomyocytes shift toward glucose and a reduction in fatty acid utilization. Calorie restriction induces weight loss in obese patients and can be beneficial in some HF patients, although this has generated some controversy. This study aims to evaluate the impact of the CR diet on myocardial efficiency in HF patients.

METHODS

On Pubmed and Embase, articles related to the keywords: "chronic heart failure" with "diet," "nutrition," "insulin resistance," and "caloric restriction" have been searched, Studies, including exercise or food supplementation, were excluded.

RESULTS

The retrieved articles showed that weight loss, through the activation of insulin and various kinase pathways, regulates the efficiency of myocardial tissue. In contrast, insulin resistance represents a strong cardiovascular risk factor that reduces myocardial function.

CONCLUSION

CR diet represents the first therapy in overweight HF patients, both with preserved ejection fraction (HFpEF) and with reduced ejection fraction (HFrHF) because reducing body fat, the myocardial function increased. Insulin activity is the critical hormone that regulates mitochondrial function and cardiac efficiency. However, a severely restricted diet may represent a severe risk factor correlated with all-cause mortality, particularly in underweight HF patients. Long-term studies conducted on large populations are necessary to evaluate the effects of CR on myocardial function in HF patients.

Range of plasma brain natriuretic peptide (BNP) levels in hemodialysis patients at a high risk of 1-year mortality and their relationship with the nutritional status: a retrospective cohort study in one institute

Background

Brain natriuretic peptide (BNP) levels are used as a marker of heart failure, which is the leading cause of morbidity and mortality in dialysis patients. BNP levels increase as renal function declines. The range of BNP levels associated with satisfactory longevity in dialysis patients currently remains unknown.

Methods

In total, 660 patients receiving maintenance hemodialysis were enrolled. BNP levels were measured at the end of the year and in a follow-up to assess 1-year mortality between 2008 and 2012. Patients were divided into six groups according to BNP levels: < 50 (reference), 50 to < 100, 100 to < 300, 300 to < 500, 500 to < 1000, and ≥ 1000 pg/mL. One-year mortality at each BNP level was analyzed using Cox’s proportional hazards model after adjustments for confounding factors.

Results

During the follow-up period, 78 (11.8%) deaths were recorded. After adjustments for confounding factors, such as gender, age, hemodialysis vintage, and primary disease, the risk of 1-year mortality was significantly high with BNP levels of 500 to < 1000 (hazard ratio [HR] 3.010; 95% confidence interval [CI] 1.065–10.729; P = 0.037) and more than 1000 pg/mL (HR 5.291; 95%CI 2.014–18.170; P = 0.0003). After adjustments for Kt/V, the risk of 1-year mortality was also significantly high with BNP levels of 500 to < 1000 (HR 3.045; 95%CI 1.065–10.929; P = 0.037) and more than 1000 pg/mL (HR 5.221; 95%CI 1.943–18.165; P = 0.0006). Following further adjustments for nutritional factors, such as albumin levels, total cholesterol levels, the normalized protein catabolic rate (nPCR), body mass index (BMI), and percent creatinine generation rate (%CGR), BNP levels of 500–1000 (HR 1.990; 95%CI 0.639–7.570; P = 0.244), and more than 1000 pg/mL (HR 2.100; 95%CI 0.663–8.105; P = 0.213) were no longer risk factors.

Conclusion

In dialysis patients, a BNP level ≥ 500 pg/mL is a risk factor for 1-year mortality. The risk associated with high BNP levels is reduced by nutritional factors, which suggests a relationship between high BNP levels and the nutritional status. In conclusion, efforts are needed to maintain BNP levels at lower than 500 pg/mL and improve the nutritional status.

Guidelines for parenteral and enteral nutrition in geriatric patients in China

Based on the expert consensus on parenteral and enteral nutrition support for geriatric patients in China in 2013, domestic multidisciplinary experts were gathered to summarize the new evidence in the field of elderly nutritional support at home and abroad. The 2013 consensus was comprehensively updated and upgraded to a guideline by referring to the World Health Organization (WHO) guidelines for the Grading of Recommendations Assessment, Development, and Evaluation system for grading evidence. These guidelines were divided into two parts: general conditions and common diseases. After discussion by all members of the academic group and consultation with relevant experts, 60 recommendations were ultimately established as standardized nutritional support in the field of geriatrics in China.

High-fat diet affects skeletal muscle mitochondria comparable to pressure overload-induced heart failure

In heart failure, high-fat diet (HFD) may exert beneficial effects on cardiac mitochondria and contractility. Skeletal muscle mitochondrial dysfunction in heart failure is associated with myopathy. However, it is not clear if HFD affects skeletal muscle mitochondria in heart failure as well. To induce heart failure, we used pressure overload (PO) in rats fed normal chow or HFD. Interfibrillar mitochondria (IFM) and subsarcolemmal mitochondria (SSM) from gastrocnemius were isolated and functionally characterized. With PO heart failure, maximal respiratory capacity was impaired in IFM but increased in SSM of gastrocnemius. Unexpectedly, HFD affected mitochondria comparably to PO. In combination, PO and HFD showed additive effects on mitochondrial subpopulations which were reflected by isolated complex activities. While PO impaired diastolic as well as systolic cardiac function and increased glucose tolerance, HFD did not affect cardiac function but decreased glucose tolerance. We conclude that HFD and PO heart failure have comparable effects leading to more severe impairment of IFM. Glucose tolerance seems not causally related to skeletal muscle mitochondrial dysfunction. The additive effects of HFD and PO may suggest accelerated skeletal muscle mitochondrial dysfunction when heart failure is accompanied with a diet containing high fat.

Sodium Intake and Target Organ Damage in Hypertension-An Update about the Role of a Real Villain

Salt intake is too high for safety nowadays. The main active ion in salt is sodium. The vast majority of scientific evidence points out the importance of sodium restriction for decreasing cardiovascular risk. International Guidelines recommend a large reduction in sodium consumption to help reduce blood pressure, organ damage, and cardiovascular risk. Regulatory authorities across the globe suggest a general restriction of sodium intake to prevent cardiovascular diseases. In spite of this seemingly unanimous consensus, some researchers claim to have evidence of the unhealthy effects of a reduction of sodium intake, and have data to support their claims. Evidence is against dissenting scientists, because prospective, observational, and basic research studies indicate that sodium is the real villain: actual sodium consumption around the globe is far higher than the safe range. Sodium intake is directly related to increased blood pressure, and independently to the enlargement of cardiac mass, with a possible independent role in inducing left ventricular hypertrophy. This may represent the basis of myocardial ischemia, congestive heart failure, and cardiac mortality. Although debated, a high sodium intake may induce initial renal damage and progression in both hypertensive and normotensive subjects. Conversely, there is general agreement about the adverse role of sodium in cerebrovascular disease. These factors point to the possible main role of sodium intake in target organ damage and cardiovascular events including mortality. This review will endeavor to outline the existing evidence.

β-Alanine and l-histidine supplementation associated with combined training increased functional capacity and maximum strength in heart failure rats

NEW FINDINGS

What is the central question of the study? Does β-alanine with l-histidine supplementation associated with endurance and strength training improve echocardiographic parameters, functional capacity, and maximum strength in rats with chronic heart failure? What is the main finding and its importance? β-Alanine with l-histidine supplementation associated with endurance and strength training increased functional capacity and maximum strength through increasing exercise capacity peripherally but did not affect echocardiographic parameters in rats with chronic heart failure. Combined training (CT) has been associated with positive responses in the clinical status of patients with chronic heart failure (CHF). Other non-pharmacological tools, such as amino acid supplementation, may further enhance its adaptation. However, the effects of β-alanine and l-histidine supplementation in CHF remain unclear. In the present study, the aim was to test whether supplementing carnosine precursors with CT could give improved responses in the functional capacity and echocardiographic variables of rats with CHF. Twenty-four Wistar rats, were submitted to myocardial infarction and allocated to three groups: animals with CHF kept in sedentary conditions (SED, n = 8), animals with CHF submitted to CT in strength and aerobic exercise supplemented with placebo (CT-P, n = 8) and animals with CHF submitted to CT in strength and aerobic exercise supplemented with β-alanine and l-histidine (CT-S, n = 8). The trained animals were submitted to a strength protocol three times per week with intensity of 65-75% of one repetition maximum test. Aerobic training was conducted two times per week (50 min, 15 m min^-1 ). The supplemented group received β-alanine and l-histidine orally (each 250 mg kg^-1  day^-1 ). No changes in echocardiographic and morphological parameters were found among the groups (P > 0.05). Functional capacity, Δ V ̇ O 2 max and maximum strength were higher in CT-P than in SED and even higher in CT-S than in CT-P (P < 0.01). The CT was able to improve functional capacity, but the supplementation was shown to enhance these parameters even further in the CHF rats. We conclude that the increase in functional capacity and strength gained through CT and supplementation were associated with the improvement in peripheral parameters with no changes in cardiac variables.

Utility of the Nutritional Screening in Predicting Adverse Outcome of Patients With Overweight/Obesity and Acute Heart Failure

BACKGROUND

Undernutrition is a negative predictor of adverse outcomes in patients with heart failure (HF). Despite the survival advantage of elevated body mass index (BMI) in patients with HF, BMI does not necessarily reflect a favorable nutritional status. In the present study, we investigated the clinical impact of nutritional screening in patients with HF and overweight/obesity.

METHODS

We examined the data from 170 patients with overweight or obesity status (defined as BMI ≥ 25 kg/m²) who admitted for acute HF. Their controlling nutritional status (CONUT) score was calculated on admission. The CONUT score is regarded as an index of the nutritional status.

RESULTS

The median duration of follow-up was 1096 days (interquartile range, 805-1096 days). Undernutrition was identified in 66.5% of the patients. Kaplan-Meier survival analysis demonstrated that patients with undernutrition had a higher incidence of all-cause death and readmission due to HF than those without undernutrition. Multivariate Cox regression analysis revealed that the CONUT score, but not BMI and the geriatric nutritional risk index, was independently correlated with poor prognosis.

CONCLUSIONS

Undernutrition is highly prevalent and independently predicts poor outcomes in patients with overweight/obesity and acute HF.

Weakness Is Associated with Time to Incident Chronic Heart Failure in Aging Americans

OBJECTIVE

Handgrip strength is considered a biomarker of nutritional status and strength capacity, which are both linked to heart complications. However, it is not well understood how weakness, as measured by handgrip strength, factors into common heart conditions seen in aging adults such as chronic heart failure (CHF). The purpose of this study was to determine the association between weakness and incident CHF for aging Americans.

DESIGN

Longitudinal-Panel.

SETTING

Physical measures were completed during enhanced face-to-face interviews. The core interview was typically conducted over the telephone.

PARTICIPANTS

Data from 17,431 adults aged at least 50 years who identified as Black or White, completed interviews without a proxy, and participated in at least one wave of the 2006-2014 waves of the Health and Retirement Study were included.

MEASUREMENTS

Handgrip strength was measured with a hand-held dynamometer. Healthcare provider diagnosed CHF was self-reported at each wave. Sex- and race-specific maximal handgrip strength cut-points were used for determining weakness (Black men: <40-kilograms, Black women: <31-kilograms, White men: <35-kilograms, White women: <22-kilograms). A covariate-adjusted Cox model analyzed the association between weakness and incident CHF.

RESULTS

Of those included, 5,397 (31.0%) were weak and 327 (1.9%) developed CHF during the mean follow-up of 4.7±2.7 years. Those who were weak had a 35% higher risk (hazard ratio: 1.35; 95% confidence interval: 1.05, 1.74) of developing CHF, compared to those who were not-weak.

CONCLUSION

Measures of handgrip strength should be utilized by healthcare providers for assessing age-related weakness, nutritional status, and CHF risk. Likewise, interventions aiming to prevent or treat CHF in aging adults should incorporate measures of handgrip strength for helping to determine efficacy of intervention programs.

Changes in the nutritional and activity status of elderly patients within 6 months of transcatheter aortic valve replacement: A mixed methods approach

AIM

Our aim was to explore changes in nutritional and activity status of patients within 6 months after transcatheter aortic valve replacement (TAVR) and factors affecting malnutrition post-TAVR in this cohort, and to gain understanding of their lifestyle considerations.

METHODS

Using a mixed methods approach, we conducted a prospective, longitudinal survey, consisting of interviews and a questionnaire, of 50 participants aged ≥70 years (mean age, 83 years; 58.0% female) undergoing TAVR. Mini Nutritional Assessment (MNA) and albumin level (to measure nutritional status) and Physical Component Summary (PCS) scores from the 36-item Short Form Health Survey (to measure activity status) were collected at pre-TAVR and 1 month and 6 months post-TAVR. Laboratory data and some index scores (e.g., the Clinical Frailty Scale [CFS] and the Mini-Mental State Examination [MMSE]) assessed before TAVR were collected from medical records as related factors.

RESULTS

Significant change was observed only in the MNA scores of participants who were assessed as malnourished at pre-TAVR, which improved, but did not reach normal nutritional status. Low-flow low-gradient aortic stenosis (odds ratio [OR]: 166.39, 95% confidence interval [CI]: 5.43-5094.43), higher CFS scores (OR: 2.58, 95% CI: 1.01-6.54), and lower MMSE scores (OR: 0.65, 95% CI: 0.43-0.99) were related to malnutrition post-TAVR. From interviews, three themes emerged: "balancing heart-healthy lifestyle and longstanding habits," "living with aging and disease" and "prospects for the rest of life."

CONCLUSIONS

Our results could be utilized to identify patients at risk of malnutrition post-TAVR, and to provide support with consideration of their lifestyle concerns.

Malnutrition in pulmonary arterial hypertension: a possible role for dietary intervention

PURPOSE OF REVIEW

The last decade's progress has been made in the pharmacological treatment of pulmonary arterial hypertension (PAH). The role of nutrition in relation to quality of life in this group of patients is not investigated yet. In addition to avoiding salt and high-fluid intake based on left heart failure diet, there is no evidence-based diet recommendation for PAH.

RECENT FINDINGS

It was recently demonstrated that patients with PAH suffer from malnutrition resulting in iron and vitamin D deficiency and glucose/insulin resistance. Recent experimental studies suggest that besides reduced malabsorption of important nutrients, the microbiome of the gut is also less diverse in PAH. In this review, we summarize the current knowledge on malnutrition and dietary intake in PAH. We discuss the possible underlying mechanisms and discuss novel therapeutic interventions validated in patients with left heart failure.

SUMMARY

Large-scaled studies on dietary interventions are needed in PAH.

[Functional recovery of the cardio-respiratory patient]

Introduction

Heart failure (HF), chronic obstructive pulmonary disease (COPD), and most chronic diseases are associated with mild to moderate chronic or recurrent inflammation. This inflammation contributes to malnutrition through different mechanisms: anorexia, decreased intake, alteration of metabolism with increased energy expenditure at rest and increased muscle catabolism. The decrease in lean mass has been included as a phenotypic criterion in the recently coined definition of malnutrition. In addition, a greater importance is given to the evaluation of the function, together with that of the morphological parameters. The grip strength, measured with a manual dynamometer and compared to reference populations, is a simple measure of muscle strength and correlates with the strength of the legs. On the other hand, the so-called "paradox of obesity" occurs in both patients with HF and COPD, since overweight and obese patients have lower overall mortality than patients with normal or low body mass index (BMI). The nutritional treatment, with an adequate contribution of macro and micronutrients and a contribution of proteins of fast absorption, with a higher content of leucine or its metabolite β-hydroxy-β-methylbutyrate, seems to offer a benefit in the preservation of muscle mass and its functionality in the patient with cardiorespiratory pathology. Nutritional treatment, associated with a pulmonary or cardiac rehabilitation regimen, is essential to obtain good morphological and functional results.

Knowledge among patients with heart failure: A narrative synthesis of qualitative research

BACKGROUND

Patients' knowledge of heart failure (HF) is integral to improved outcomes. However, the HF literature has not adequately explored the nature of patients' knowledge of HF as part of their lived experience.

OBJECTIVES

We aimed to characterize the nature of patients' knowledge of HF, in the context of living with the disease.

METHODS

We conducted a narrative synthesis of qualitative studies that addressed patients' knowledge of HF. Studies were systematically searched and retrieved from MEDLINE, CINAHL, PsycINFO and PsycARTICLES databases. Findings were synthesized using an iterative coding process carried out by multiple analysts and reported following Enhancing Transparency in the Reporting of Qualitative Health Research (ENTREQ) criteria.

RESULTS

Analysis of 73 eligible articles produced five themes: the content that comprises HF knowledge; development of HF knowledge over time; application of HF knowledge for decision making; communication of information between clinicians and patients; and patients' experience of knowledge.

CONCLUSION

The nature of patients' knowledge of HF is both explicit and implicit, dynamic, and personal. This multidimensional model of knowledge-in-context calls for equally multidimensional research and intervention design.

Nutritional Interventions in Heart Failure: Challenges and Opportunities

PURPOSE OF REVIEW

There is a growing body of evidence that nutritional factors influence the incidence of heart failure (HF). The current manuscript aims to collate evidence relating to nutritional intervention in the treatment of HF as well as to provide context regarding challenges and opportunities in the field.

RECENT FINDINGS

Despite the accepted importance of nutritional factors relating to cardiovascular disease severity, there is surprisingly little human intervention research regarding dietary intake and HF. Further, existing nutritional interventions in HF were mostly pilot studies with small samples and short follow-up. There is consistent evidence that nutritional factors majorly influence HF. Despite limited research, there is evidence that nutritional modification can rapidly and profoundly influence multiple aspects of HF. There is an urgent need for well-conducted research to ascertain if nutritional modification can alter the long-term course of HF.

Reduced Salt Intake for Heart Failure: A Systematic Review

IMPORTANCE

Recent estimates suggest that more than 26 million people worldwide have heart failure. The syndrome is associated with major symptoms, significantly increased mortality, and extensive use of health care. Evidence-based treatments influence all these outcomes in a proportion of patients with heart failure. Current management also often includes advice to reduce dietary salt intake, although the benefits are uncertain.

OBJECTIVE

To systematically review randomized clinical trials of reduced dietary salt in adult inpatients or outpatients with heart failure.

EVIDENCE REVIEW

Several bibliographic databases were systematically searched, including the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, and CINAHL. The methodologic quality of the studies was evaluated, and data associated with primary outcomes of interest (cardiovascular-associated mortality, all-cause mortality, and adverse events, such as stroke and myocardial infarction) and secondary outcomes (hospitalization, length of inpatient stay, change in New York Heart Association [NYHA] functional class, adherence to dietary low-salt intake, and changes in blood pressure) were extracted.

FINDINGS

Of 2655 retrieved references, 9 studies involving 479 unique participants were included in the analysis. None of the studies included more than 100 participants. The risks of bias in the 9 studies were variable. None of the included studies provided sufficient data on the primary outcomes of interest. For the secondary outcomes of interest, 2 outpatient-based studies reported that NYHA functional class was not improved by restriction of salt intake, whereas 2 studies reported significant improvements in NYHA functional class.

CONCLUSIONS AND RELEVANCE

Limited evidence of clinical improvement was available among outpatients who reduced dietary salt intake, and evidence was inconclusive for inpatients. Overall, a paucity of robust high-quality evidence to support or refute current guidance was available. This review suggests that well-designed, adequately powered studies are needed to reduce uncertainty about the use of this intervention.

PROTOCOL REGISTRATION

PROSPERO Identifier: CRD42015019504.

Dietary patterns and components to prevent and treat heart failure: a comprehensive review of human studies

Growing evidence has emerged about the role of dietary patterns and components in heart failure (HF) incidence and severity. The objective here is to provide a comprehensive summary of the current evidence regarding dietary patterns/components and HF. A comprehensive search of online databases was conducted using multiple relevant keywords to identify relevant human studies. The Dietary Approaches to Stop Hypertension (DASH) and Mediterranean diets have consistently been associated with decreased HF incidence and severity. Regarding specific dietary components, fruit, vegetables, legumes and whole grains appear beneficial. Current evidence suggests that red/processed meats, eggs and refined carbohydrates are harmful, while fish, dairy products and poultry remain controversial. However, there is a notable lack of human intervention trials. The existing but limited observational and interventional evidence from human studies suggests that a plant-based dietary pattern high in antioxidants, micronutrients, nitrate and fibre but low in saturated/trans-fat and Na may decrease HF incidence/severity. Potential mechanisms include decreased oxidative stress, homocysteine and inflammation but higher antioxidant defence and NO bioavailability and gut microbiome modulation. Randomised, controlled trials are urgently required.

Hospital Management of Acute Decompensated Heart Failure

Heart failure (HF) is one of the leading causes of hospitalizations for elderly adults in the United States. One in 5 Americans will be >65 years of age by 2050. Because of the high prevalence of HF in this group, the number of Americans requiring hospitalization for this disorder is expected to rise significantly. We reviewed the most recent and ongoing studies and recommendations for the management of patients hospitalized due to decompensated HF. The Acute Decompensated Heart Failure National Registry, together with the 2013 American College of Cardiology Foundation and American Heart Association heart failure guidelines, earlier retrospective and prospective studies including the Diuretic Optimization Strategies Evaluation (DOSE), the Trial of Intensified vs Standard Medical Therapy in the Elderly Patients With Congestive Heart Failure (TIME-CHF), the Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure (OPTIMIZE-HF), the Rapid Emergency Department Heart Failure Outpatient Trial (REDHOT) and the Comparison of Medical, Pacing and Defibrillation Therapies in Heart Failure (COMPANION) trial were reviewed for current practices pertaining to these patients. Gaps in our knowledge of optimal use of patient-specific information (biomarkers and comorbid conditions) still exist.

Improving Treatment Adherence in Heart Failure

BACKGROUND

Despite improved treatment options, heart failure remains the third most common cause of death in Germany and the most common reason for hospitalization. The treatment recommendations contained in the relevant guidelines have been incompletely applied in practice. The goal of this systematic review is to study the efficacy of adherence-promoting interventions for patients with heart failure with respect to the taking of medications, the implementation of recommended lifestyle changes, and the improvement in clinical endpoints.

METHODS

We performed a meta-analysis of pertinent publications retrieved by a systematic literature search.

RESULTS

55 randomized controlled trials were identified, in which a wide variety of interventions were carried out on heterogeneous patient groups with varying definitions of adherence. These trials included a total of 15 016 patients with heart failure who were cared for as either inpatients or outpatients. The efficacy of interventions to promote adherence to drug treatment was studied in 24 trials; these trials documented improved adherence in 10% of the patients overall (95% confidence interval [CI]: [5; 15]). The efficacy of interventions to promote adherence to lifestyle recommendations was studied in 42 trials; improved adherence was found in 31 trials. Improved adherence to at least one recommendation yielded a long-term absolute reduction in mortality of 2% (95% CI: [0; 4]) and a 10% reduction in the likelihood of hospitalization within 12 months of the start of the intervention (95% CI: [3; 17]).

CONCLUSION

Many effective interventions are available that can lead to sustained improvement in patient adherence and in clinical endpoints. Longterm success depends on patients' assuming responsibility for their own health and can be achieved with the aid of coordinated measures such as patient education and regular follow-up contacts.