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Tkaczyszyn M, Comín-Colet J, Voors AA, van Veldhuisen DJ, Enjuanes C, Moliner P, Drozd M, Sierpiński R, Rozentryt P, Nowak J, Suchocki T, Banasiak W, Ponikowski P, van der Meer P, Jankowska EA. Iron deficiency contributes to resistance to endogenous erythropoietin in anaemic heart failure patients. Eur J Heart Fail 2021; 23:1677-1686. [PMID: 34050579 DOI: 10.1002/ejhf.2253] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 04/22/2021] [Accepted: 05/24/2021] [Indexed: 11/07/2022] Open
Abstract
AIMS Abnormal endogenous erythropoietin (EPO) constitutes an important cause of anaemia in chronic diseases. We analysed the relationships between iron deficiency (ID) and the adequacy of endogenous EPO in anaemic heart failure (HF) patients, and the impact of abnormal EPO on 12-month mortality. METHODS AND RESULTS We investigated 435 anaemic HF patients (age: 74 ± 10 years; males: 60%; New York Heart Association class I or II: 39%; left ventricular ejection fraction: 43 ± 17%). Patients with EPO higher than expected for a given haemoglobin were considered EPO-resistant whereas those with EPO lower than expected - EPO-deficient. ID was defined as serum ferritin <100 µg/L or 100-299 µg/L with transferrin saturation <20%. EPO-resistant patients (22%) had more advanced HF whereas those with EPO deficiency (57%) were more frequently females and had worse renal function. Lower serum ferritin (indicating depleted body iron stores) was related to higher EPO observed/predicted ratio when adjusted for significant clinical confounders, including C-reactive protein. One year all-cause mortality was 28% in patients with EPO resistance compared to 17% in patients with EPO deficiency and 10% in patients with adequate EPO (log-rank test for the comparison EPO resistance vs. adequate EPO: P = 0.02). When adjusted for other prognosticators, there was still a trend towards increased 12-month mortality in patients with higher EPO level. CONCLUSION Anaemic HF patients with endogenous EPO deficiency vs. resistance have different clinical and laboratory characteristics. In such patients, ID contributes to EPO resistance independently of inflammation.
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Affiliation(s)
- Michał Tkaczyszyn
- Department of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland.,Centre for Heart Diseases, University Hospital, Wroclaw, Poland
| | - Josep Comín-Colet
- Bio-Heart Cardiovascular Diseases Research Group, Bellvitge Biomedical Research Institute (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain.,Community Heart Failure Program, Cardiology Department, University Hospital Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Adriaan A Voors
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Dirk J van Veldhuisen
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Cristina Enjuanes
- Bio-Heart Cardiovascular Diseases Research Group, Bellvitge Biomedical Research Institute (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain.,Community Heart Failure Program, Cardiology Department, University Hospital Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Pedro Moliner
- Bio-Heart Cardiovascular Diseases Research Group, Bellvitge Biomedical Research Institute (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain.,Community Heart Failure Program, Cardiology Department, University Hospital Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Marcin Drozd
- Department of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland.,Centre for Heart Diseases, University Hospital, Wroclaw, Poland
| | | | - Piotr Rozentryt
- Silesian Centre for Heart Disease and Silesian Medical University, Zabrze, Poland
| | - Jolanta Nowak
- Silesian Centre for Heart Disease and Silesian Medical University, Zabrze, Poland
| | - Tomasz Suchocki
- Biostatistics Group, Department of Genetics, Wroclaw University of Environmental and Life Sciences, Wroclaw, Poland
| | - Waldemar Banasiak
- Cardiology Department, Centre for Heart Diseases, Military Hospital, Wroclaw, Poland
| | - Piotr Ponikowski
- Department of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland.,Centre for Heart Diseases, University Hospital, Wroclaw, Poland
| | - Peter van der Meer
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Ewa A Jankowska
- Department of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland.,Centre for Heart Diseases, University Hospital, Wroclaw, Poland
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Abstract
OBJECTIVES Health-related quality of life (HR-QoL) of patients with heart failure (HF) is low despite the aim of HF treatment to improve HR-QoL. To date, most studies have focused on medical and physical factors in relation to HR-QoL, few data are available on the role of emotional factors such as dispositional optimism. This study examines the prevalence of optimism and pessimism in HF patients and investigates how optimism and pessimism are associated with different patient characteristics and HR-QoL. METHODS Dispositional optimism was assessed in 86 HF patients (mean age 70 ± 9 years, 28% female, mean left ventricular ejection fraction 33%) with the Revised Life Orientation Test (LOT-R). HR-QoL was assessed with the Minnesota Living with Heart Failure Questionnaire and the EuroQol. RESULTS The (mean ± SD) total score on the LOT-R was 14.6 ± 2.9 (theoretical range 0-24) and the scores on the subscales optimism and pessimism were 8.1 ± 1.9 and 5.5 ± 2.5, respectively. Higher age was related to more optimism (r = 0.22, p < 0.05), and optimism was associated with higher generic HR-QoL (B = 0.04, p < 0.05).Significance of resultsThe association found between optimism and generic HR-QoL of HF patients can lead to promising strategies to improve HF patients' HR-QoL, particularly because the literature has indicated that optimism is a modifiable condition.
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3
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Moliner P, Jankowska EA, van Veldhuisen DJ, Farre N, Rozentryt P, Enjuanes C, Polonski L, Meroño O, Voors AA, Ponikowski P, Van der Meer P, Comin-Colet J. Clinical correlates and prognostic impact of impaired iron storage versus impaired iron transport in an international cohort of 1821 patients with chronic heart failure. Int J Cardiol 2017; 243:360-366. [DOI: 10.1016/j.ijcard.2017.04.110] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Revised: 04/06/2017] [Accepted: 04/17/2017] [Indexed: 01/08/2023]
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Tkaczyszyn M, Comín-Colet J, Voors AA, van Veldhuisen DJ, Enjuanes C, Moliner-Borja P, Rozentryt P, Poloński L, Banasiak W, Ponikowski P, van der Meer P, Jankowska EA. Iron deficiency and red cell indices in patients with heart failure. Eur J Heart Fail 2017; 20:114-122. [PMID: 28386910 DOI: 10.1002/ejhf.820] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Revised: 01/29/2017] [Accepted: 02/24/2017] [Indexed: 12/17/2022] Open
Abstract
AIMS To investigate the prevalence of iron deficiency (ID) in heart failure (HF) patients with normal vs. abnormal red cell indices (RCI), the associations between iron parameters and RCI, and prognostic consequences of ID independently of RCI. METHODS AND RESULTS We analysed clinical data of 1821 patients with HF [mean age 66 ± 13 years; 71% men; New York Heart Association class I/II/III/IV (11%/39%/44%/6%); left ventricular ejection fraction >45%: 19%]. Iron deficiency (ferritin <100 µg/L or ferritin 100-299 µg/L with transferrin saturation <20%) was common irrespective of the presence of anaemia (haemoglobin <12 g/dL in women and <13 g/dL in men) or low RCI, from 75% in anaemic subjects with low mean corpuscular volume (MCV), mean corpuscular haemoglobin (MCH), and MCH concentration (MCHC), to 36% in non-anaemic subjects with MCV, MCH, and MCHC above the lower limit of normal. After adjustment for clinical variables, iron parameters remained independently associated with haemoglobin, MCV, MCH, MCHC, mean reticulocyte haemoglobin content (CHR), and red cell distribution width (RDW). In multivariable Cox proportional hazard regression models there was a trend towards higher mortality in patients with vs. without ID when adjusted for relevant HF prognosticators and MCH or MCHC (but not haemoglobin, CHR or RDW). CONCLUSIONS Patients with HF should be routinely screened for ID irrespective of the presence of anaemia or abnormal RCI. The detrimental impact of ID on long-term survival in HF is partially independent of RCI.
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Affiliation(s)
- Michał Tkaczyszyn
- Laboratory for Applied Research on Cardiovascular System, Department of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland.,Cardiology Department, Centre for Heart Diseases, Military Hospital, Wroclaw, Poland
| | - Josep Comín-Colet
- Heart Diseases Biomedical Research Group, Program of Research in Inflammatory and Cardiovascular Disorders, IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain.,Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Adriaan A Voors
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Dirk J van Veldhuisen
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Cristina Enjuanes
- Heart Diseases Biomedical Research Group, Program of Research in Inflammatory and Cardiovascular Disorders, IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain.,Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Pedro Moliner-Borja
- Heart Diseases Biomedical Research Group, Program of Research in Inflammatory and Cardiovascular Disorders, IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain.,Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Piotr Rozentryt
- 3rd Department of Cardiology, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Silesia, Katowice, Silesian Centre for Heart Disease in Zabrze, Poland
| | - Lech Poloński
- 3rd Department of Cardiology, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Silesia, Katowice, Silesian Centre for Heart Disease in Zabrze, Poland
| | - Waldemar Banasiak
- Cardiology Department, Centre for Heart Diseases, Military Hospital, Wroclaw, Poland
| | - Piotr Ponikowski
- Cardiology Department, Centre for Heart Diseases, Military Hospital, Wroclaw, Poland.,Department of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
| | - Peter van der Meer
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Ewa A Jankowska
- Laboratory for Applied Research on Cardiovascular System, Department of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland.,Cardiology Department, Centre for Heart Diseases, Military Hospital, Wroclaw, Poland
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5
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Bos-Touwen I, Jonkman N, Westland H, Schuurmans M, Rutten F, de Wit N, Trappenburg J. Tailoring of self-management interventions in patients with heart failure. Curr Heart Fail Rep 2016; 12:223-35. [PMID: 25929690 PMCID: PMC4424272 DOI: 10.1007/s11897-015-0259-3] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
The effectiveness of heart failure (HF) self-management interventions varies within patients suggesting that one size does not fit all. It is expected that effectiveness can be optimized when interventions are tailored to individual patients. The aim of this review was to synthesize the literature on current use of tailoring in self-management interventions and patient characteristics associated with self-management capacity and success of interventions, as building blocks for tailoring. Within available trials, the degree to which interventions are explicitly tailored is marginal and often limited to content. We found that certain patient characteristics that are associated with poor self-management capacity do not influence effectiveness of a given intervention (i.e., age, gender, ethnicity, disease severity, number of comorbidities) and that other characteristics (low: income, literacy, education, baseline self-management capacity) in fact are indicators of patients with a high likelihood for success. Increased scientific efforts are needed to continue unraveling success of self-management interventions and to validate the modifying impact of currently known patient characteristics.
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Affiliation(s)
- Irene Bos-Touwen
- />Department Rehabilitation, Nursing Science & Sports, University Medical Center Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands
| | - Nini Jonkman
- />Department Rehabilitation, Nursing Science & Sports, University Medical Center Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands
| | - Heleen Westland
- />Department Rehabilitation, Nursing Science & Sports, University Medical Center Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands
| | - Marieke Schuurmans
- />Department Rehabilitation, Nursing Science & Sports, University Medical Center Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands
| | - Frans Rutten
- />Julius Center, Department of General Practice, University Medical Center Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands
| | - Niek de Wit
- />Julius Center, Department of General Practice, University Medical Center Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands
| | - Jaap Trappenburg
- />Department Rehabilitation, Nursing Science & Sports, University Medical Center Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands
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Kraai I, de Vries A, Vermeulen K, van Deursen V, van der Wal M, de Jong R, van Dijk R, Jaarsma T, Hillege H, Lesman I. The value of telemonitoring and ICT-guided disease management in heart failure: Results from the IN TOUCH study. Int J Med Inform 2015; 85:53-60. [PMID: 26514079 DOI: 10.1016/j.ijmedinf.2015.10.001] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2015] [Revised: 10/07/2015] [Accepted: 10/08/2015] [Indexed: 11/25/2022]
Abstract
AIM It is still unclear whether telemonitoring reduces hospitalization and mortality in heart failure (HF) patients and whether adding an Information and Computing Technology-guided-disease-management-system (ICT-guided-DMS) improves clinical and patient reported outcomes or reduces healthcare costs. METHODS A multicenter randomized controlled trial was performed testing the effects of INnovative ICT-guided-DMS combined with Telemonitoring in OUtpatient clinics for Chronic HF patients (IN TOUCH) with in total 179 patients (mean age 69 years; 72% male; 77% in New York Heart Association Classification (NYHA) III-IV; mean left ventricular ejection fraction was 28%). Patients were randomized to ICT-guided-DMS or to ICT-guided-DMS+telemonitoring with a follow-up of nine months. The composite endpoint included mortality, HF-readmission and change in health-related quality of life (HR-QoL). RESULTS In total 177 patients were eligible for analyses. The mean score of the primary composite endpoint was -0.63 in ICT-guided-DMS vs. -0.73 in ICT-guided-DMS+telemonitoring (mean difference 0.1, 95% CI: -0.67 +0.82, p=0.39). All-cause mortality in ICT-guided-DMS was 12% versus 15% in ICT-guided-DMS+telemonitoring (p=0.27); HF-readmission 28% vs. 27% p=0.87; all-cause readmission was 49% vs. 51% (p=0.78). HR-QoL improved in most patients and was equal in both groups. Incremental costs were €1360 in favor of ICT-guided-DMS. ICT-guided-DMS+telemonitoring had significantly fewer HF-outpatient-clinic visits (p<0.01). CONCLUSION ICT-guided-DMS+telemonitoring for the management of HF patients did not affect the primary and secondary endpoints. However, we did find a reduction in visits to the HF-outpatient clinic in this group suggesting that telemonitoring might be safe to use in reorganizing HF-care with relatively low costs.
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Affiliation(s)
- Imke Kraai
- Department of Cardiology, University Medical Center Groningen, University of Groningen, The Netherlands.
| | - Arjen de Vries
- Department of Cardiology, University Medical Center Groningen, University of Groningen, The Netherlands
| | - Karin Vermeulen
- Department of Epidemiology, University Medical Center Groningen, University of Groningen, The Netherlands
| | - Vincent van Deursen
- Department of Cardiology, University Medical Center Groningen, University of Groningen, The Netherlands
| | - Martje van der Wal
- Linköping University, Faculty of Health Sciences, Department of Social and Welfare Studies, Linköping, Sweden
| | - Richard de Jong
- Department of Cardiology, Wilhelmina Hospital Assen, The Netherlands
| | - René van Dijk
- Department of Cardiology, Cavari Clinics Groningen, The Netherlands
| | - Tiny Jaarsma
- Linköping University, Faculty of Health Sciences, Department of Social and Welfare Studies, Linköping, Sweden
| | - Hans Hillege
- Department of Epidemiology, University Medical Center Groningen, University of Groningen, The Netherlands
| | - Ivonne Lesman
- Department of Epidemiology, University Medical Center Groningen, University of Groningen, The Netherlands
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7
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Lok SI, Lok DJ, van der Weide P, Winkens B, Bruggink-André de la Porte PW, Doevendans PA, de Weger RA, van der Meer P, de Jonge N. Plasma levels of alpha-1-antichymotrypsin are elevated in patients with chronic heart failure, but are of limited prognostic value. Neth Heart J 2014; 22:391-5. [PMID: 25172361 PMCID: PMC4160451 DOI: 10.1007/s12471-014-0584-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Background There is increasing interest in utilising novel markers of cardiovascular disease risk in patients with chronic heart failure (HF). Recently, it was shown that alpha-1-antichymotrypsin (ACT), an acute-phase protein and major inhibitor of cathpesin G, plays a role in the pathophysiology of HF and may serve as a marker for myocardial distress. Objective To assess whether ACT is independently associated with long-term mortality in chronic HF patients. Methods ACT plasma levels were categorised into quartiles. Survival times were analysed using Kaplan-Meier curves and Cox proportional hazards regression, without and with correction for clinically relevant risk factors, including sex, age, duration of HF, kidney function (MDRD), ischaemic HF aetiology and NT-proBNP. Results Twenty healthy individuals and 224 patients (mean age 71 years, 72 % male, median HF duration 1.6 years) with chronic HF were included. In total, 159 (71 %) patients died. The median survival time was 5.3 (95 % CI 4.5–6.1) years. ACT was significantly elevated in patients (median 433 μg/ml, IQR 279–680) in comparison with controls (median 214 μg/ml, IQR 166–271; p < 0.001). Cox regression analysis demonstrated that ACT was not independently related to long-term mortality in chronic HF patients (crude HR = 1.03, 95 % CI 0.75–1.41, p = 0.871; adjusted HR = 1.12, 95 % CI 0.78–1.60, p = 0.552), which was confirmed by Kaplan-Meier curves. Conclusion ACT levels are elevated in chronic HF patients, but no independent association with long-term mortality can be established.
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Affiliation(s)
- S I Lok
- Department of Cardiology, University Medical Center, Huispostnummer H04.312, PO Box 85500, 3508 GA, Utrecht, the Netherlands,
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8
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Enjuanes C, Klip IT, Bruguera J, Cladellas M, Ponikowski P, Banasiak W, van Veldhuisen DJ, van der Meer P, Jankowska EA, Comín-Colet J. Iron deficiency and health-related quality of life in chronic heart failure: results from a multicenter European study. Int J Cardiol 2014; 174:268-75. [PMID: 24768464 DOI: 10.1016/j.ijcard.2014.03.169] [Citation(s) in RCA: 139] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2013] [Revised: 03/10/2014] [Accepted: 03/26/2014] [Indexed: 01/31/2023]
Abstract
Patients affected by chronic heart failure (CHF) present significant impairment of health-related quality of life (HRQoL). Iron deficiency (ID) is a common comorbidity in CHF with negative impact in prognosis and functional capacity. The role of iron in energy metabolism could be the link between ID and HRQoL. There is little information about the role of ID on HRQoL in patients with CHF. We evaluate the impact of ID on HRQoL and the interaction with the anaemia status, iron status, clinical baseline information and HRQoL, measured with the Minnesota Living with Heart Failure questionnaire (MLHFQ) was obtained at baseline in an international cohort of 1278 patients with CHF. Baseline characteristics were median age 68 ± 12, 882 (69%) were males, ejection fraction was 38% ± 15 and NYHA class was I/II/III/IV (156/247/487/66). ID (defined as ferritin level< 100 µg/L or serum ferritin 100-299 µg/L in combination with a TSAT<20%) was present in 741 patients (58%). 449 (35%) patients were anaemic. Unadjusted global scores of MLHFQ (where higher scores reflect worse HRQoL) were worse in ID and anaemic patients (ID+: 42 ± 25 vs. ID-: 37 ± 25; p-value=0.001 and A+: 46 ± 25 vs. A-: 37 ± 25; p-value<0.001). The combined influence of ID and anaemia was explored with different multivariable regression models, showing that ID but not anaemia was associated with impaired HRQoL. ID has a negative impact on HRQoL in CHF patients, and this is independent of the presence of anaemia.
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Affiliation(s)
- Cristina Enjuanes
- Heart Diseases Biomedical Research Group, Program of Research in Inflammatory and Cardiovascular Disorders, IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain; Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Ijsbrand T Klip
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Jordi Bruguera
- Heart Diseases Biomedical Research Group, Program of Research in Inflammatory and Cardiovascular Disorders, IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain
| | - Merce Cladellas
- Heart Diseases Biomedical Research Group, Program of Research in Inflammatory and Cardiovascular Disorders, IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain; Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Piotr Ponikowski
- Center for Heart Diseases, Military Hospital, Wroclaw, Poland; Department of Heart Diseases, Wroclaw Medical University, Poland
| | | | - Dirk J van Veldhuisen
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Peter van der Meer
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Ewa A Jankowska
- Center for Heart Diseases, Military Hospital, Wroclaw, Poland; Department of Heart Diseases, Wroclaw Medical University, Poland; Laboratory for Applied Research on Cardiovascular System, Department of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
| | - Josep Comín-Colet
- Heart Diseases Biomedical Research Group, Program of Research in Inflammatory and Cardiovascular Disorders, IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain; Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain.
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9
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Lok DJ, Klip IT, Lok SI, Bruggink-André de la Porte PW, Badings E, van Wijngaarden J, Voors AA, de Boer RA, van Veldhuisen DJ, van der Meer P. Incremental prognostic power of novel biomarkers (growth-differentiation factor-15, high-sensitivity C-reactive protein, galectin-3, and high-sensitivity troponin-T) in patients with advanced chronic heart failure. Am J Cardiol 2013; 112:831-7. [PMID: 23820571 DOI: 10.1016/j.amjcard.2013.05.013] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2013] [Revised: 05/02/2013] [Accepted: 05/02/2013] [Indexed: 12/11/2022]
Abstract
Elevated natriuretic peptides provide strong prognostic information in patients with heart failure (HF). The role of novel biomarkers in HF needs to be established. Our objective was to evaluate the prognostic power of novel biomarkers, incremental to the N-terminal portion of the natriuretic peptide (NT-proBNP) in chronic HF. Concentrations of circulating NT-proBNP, growth differentiation factor 15 (GDF-15), high-sensitivity C-reactive protein (hs-CRP), galectin-3 (Gal-3), and high-sensitivity troponin T (hs-TnT) were measured and related to all-cause long-term mortality. Of 209 patients (age 71 ± 10 years, 73% male patients, 97% New York Heart Association class III), 151 (72%) died during a median follow-up of 8.7 ± 1 year. The calculated area under the curve for NT-proBNP was 0.63, GDF-15 0.78, hs-CRP 0.66, Gal-3 0.68, and hs-TnT 0.68 (all p <0.01). Each marker was predictive for mortality in univariate analysis. In multivariate analysis, elevated concentrations of GDF-15 (hazard ratio [HR] 1.41, confidence interval [CI] 1.1 to 178, p = 0.005), hs-CRP (HR 1.38, CI 1.15 to 1.67, p = 0.001), and hs-TnT (HR 1.27, CI 1.06 to 1.53, p = 0.008) were independently related to mortality. All novel markers had an incremental value to NT-proBNP, using the integrated discrimination improvement. In conclusion, in chronic HF, GDF-15, hs-CRP, and hs-TnT are independent prognostic markers, incremental to NT-proBNP, in predicting long-term mortality. In this study, GDF-15 is the most predictive marker, even stronger than NT-proBNP.
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Affiliation(s)
- Dirk J Lok
- Deventer Hospital, Deventer, the Netherlands.
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10
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Iron deficiency in chronic heart failure: an international pooled analysis. Am Heart J 2013; 165:575-582.e3. [PMID: 23537975 DOI: 10.1016/j.ahj.2013.01.017] [Citation(s) in RCA: 479] [Impact Index Per Article: 43.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2012] [Accepted: 01/17/2013] [Indexed: 12/25/2022]
Abstract
BACKGROUND Iron deficiency (ID) is an emerging problem in patients with chronic heart failure (HF) and can be a potential therapeutic target. However, not much is known about the prevalence, predictors, and prognosis of ID in patients with chronic HF. METHODS In an international pooled cohort comprising 1,506 patients with chronic HF, we studied the clinical associates of ID and its prognostic consequences. RESULTS Iron deficiency (defined as a ferritin level <100 μg/L or ferritin 100-299 μg/L with a transferrin saturation <20%) was present in 753 patients (50%). Anemic patients were more often iron deficient than nonanemic patients (61.2% vs 45.6%, P < .001). Other independent predictors of ID were higher New York Heart Association class, higher N-terminal pro-brain-type natriuretic peptide levels, lower mean corpuscular volume levels, and female sex (all P < .05). During follow-up (median 1.92 years, interquartile range 1.18-3.26 years), 440 patients died (29.2%). Kaplan-Meier survival analysis revealed ID as a strong predictor for mortality (log rank χ(2) 10.2, P = .001). In multivariable hazard models, ID (but not anemia) remained a strong and independent predictor of mortality (hazard ratio 1.42, 95% confidence interval 1.14-1.77, P = .002). Finally, the presence of ID significantly enhanced risk classification and integrated discrimination improvement when added to a prediction model with established risk factors. CONCLUSIONS Iron deficiency is common in patients with chronic HF, relates to disease severity, and is a strong and independent predictor of outcome. In this study, ID appears to have greater predictive power than anemia.
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11
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Lok DJ, Lok SI, Bruggink-André de la Porte PW, Badings E, Lipsic E, van Wijngaarden J, de Boer RA, van Veldhuisen DJ, van der Meer P. Galectin-3 is an independent marker for ventricular remodeling and mortality in patients with chronic heart failure. Clin Res Cardiol 2012; 102:103-10. [PMID: 22886030 DOI: 10.1007/s00392-012-0500-y] [Citation(s) in RCA: 127] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2012] [Accepted: 07/24/2012] [Indexed: 12/14/2022]
Abstract
BACKGROUND Galectin-3 (Gal-3) is a recently discovered marker for myocardial fibrosis and elevated levels are associated with an impaired outcome after short-term follow-up in heart failure (HF) patients. However, whether Gal-3 is related to cardiac remodeling and outcome after long-term follow-up is unknown. Therefore, we determined the utility of Gal-3 as a novel biomarker for left ventricular remodeling and long-term outcome in patients with severe chronic HF. METHODS AND RESULTS A total of 240 HF patients with New York Heart Association (NYHA) Class III and IV were included. Patients were followed for 8.7 ± 1 years, had a mean age of 71 ± 0.6 years and 73 % of the study population was male. Circulating levels of NT-proBNP and Gal-3 were measured. Serial echocardiography was performed at baseline and at 3 months. At baseline median left ventricular end-diastolic volume (LVEDV) was 267 mL [interquartile range 232-322]. Patients were divided into three groups according to the change in LVEDV. Patients in whom the LVEDV decreased over time had significant lower levels of Gal-3 at entry compared to patients in whom the LVEDV was stable or increased (14.7 vs. 17.9 vs. 19.0 ng/mL; p = 0.004 for trend), whereas no significant differences were seen in levels of NT-proBNP (p = 0.33). Multivariate linear regression analyses revealed that Gal-3 levels were positively correlated to change in LVEDV (p = 0.007). In addition, Gal-3 was a significant predictor of mortality after long-term follow-up (p = 0.001). CONCLUSION Gal-3 is associated with left ventricular remodeling determined by serial echocardiography and predicts long-term mortality in patients with severe chronic HF.
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Affiliation(s)
- Dirk J Lok
- Deventer Hospital, Nico Bolkesteinlaan 75, 7415 CM, Deventer, The Netherlands.
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Leykum LK, Parchman M, Pugh J, Lawrence V, Noël PH, McDaniel RR. The importance of organizational characteristics for improving outcomes in patients with chronic disease: a systematic review of congestive heart failure. Implement Sci 2010; 5:66. [PMID: 20735859 PMCID: PMC2936445 DOI: 10.1186/1748-5908-5-66] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2010] [Accepted: 08/25/2010] [Indexed: 11/10/2022] Open
Abstract
Background Despite applications of models of care and organizational or system-level interventions to improve patient outcomes for chronic disease, consistent improvements have not been achieved. This may reflect a mismatch between the interventions and the nature of the settings in which they are attempted. The application of complex adaptive systems (CAS) framework to understand clinical systems and inform efforts to improve them may lead to more successful interventions. We performed a systematic review of interventions to improve outcomes of patients with congestive heart failure (CHF) to examine whether interventions consistent with CAS are more likely to be effective. We then examine differences between interventions that are most effective for improving outcomes for patients with CHF versus previously published data for type 2 diabetes to explore the potential impact of the nature of the disease on the types of interventions that are more likely to be effective. Methods We conducted a systematic review of the literature between 1998 and 2008 of organizational interventions to improve care of patients with CHF. Two independent reviewers independently assessed studies that met inclusion criteria to determine whether each reported intervention reflected one or more CAS characteristics. The effectiveness of interventions was rated as either 0 (no effect), 0.5 (mixed effect), or 1.0 (effective) based on the type, number, and significance of reported outcomes. Fisher's exact test was used to examine the association between CAS characteristics and intervention effectiveness. Specific CAS characteristics associated with intervention effectiveness for CHF were contrasted with previously published data for type 2 diabetes. Results and discussion Forty-four studies describing 46 interventions met eligibility criteria. All interventions utilized at least one CAS characteristic, and 85% were either 'mixed effect' or 'effective' in terms of outcomes. The number of CAS characteristics present in each intervention was associated with effectiveness (p < 0.001), supporting the idea that interventions consistent with CAS are more likely to be effective. The individual CAS characteristics associated with CHF intervention effectiveness were learning, self-organization, and co-evolution, a finding different from our previously published analysis of interventions for diabetes. We suggest this difference may be related to the degree of uncertainty involved in caring for patients with diabetes versus CHF. Conclusion These results suggest that for interventions to be effective, they must be consistent with the CAS nature of clinical systems. The difference in specific CAS characteristics associated with intervention effectiveness for CHF and diabetes suggests that interventions must also take into account attributes of the disease.
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Affiliation(s)
- Luci K Leykum
- South Texas Veterans Health Care System and Department of Medicine, University of Texas Health Science Center at San Antonio, San Antonio TX, 78229, USA.
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Peters-Klimm F, Campbell S, Hermann K, Kunz CU, Müller-Tasch T, Szecsenyi J. Case management for patients with chronic systolic heart failure in primary care: the HICMan exploratory randomised controlled trial. Trials 2010; 11:56. [PMID: 20478035 PMCID: PMC2882359 DOI: 10.1186/1745-6215-11-56] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2010] [Accepted: 05/17/2010] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Chronic (systolic) heart failure (CHF) represents a clinical syndrome with high individual and societal burden of disease. Multifaceted interventions like case management are seen as promising ways of improving patient outcomes, but lack a robust evidence base, especially for primary care. The aim of the study was to explore the effectiveness of a new model of CHF case management conducted by doctors' assistants (DAs, equivalent to a nursing role) and supported by general practitioners (GPs). METHODS This patient-randomised controlled trial (phase II) included 31 DAs and employing GPs from 29 small office-based practices in Germany. Patients with CHF received either case management (n = 99) consisting of telephone monitoring and home visits or usual care (n = 100) for 12 months. We obtained clinical data, health care utilisation data, and patient-reported data on generic and disease-specific quality of life (QoL, SF-36 and KCCQ), CHF self-care (EHFScBS) and on quality of care (PACIC-5A). To compare between groups at follow-up, we performed analyses of covariance and logistic regression models. RESULTS Baseline measurement showed high guideline adherence to evidence-based pharmacotherapy and good patient self-care: Patients received angiotensin converting enzyme inhibitors (or angiotensin-2 receptor antagonists) in 93.8% and 95%, and betablockers in 72.2% and 84%, and received both in combination in 68% and 80% of cases respectively. EHFScBS scores (SD) were 25.4 (8.4) and 25.0 (7.1). KCCQ overall summary scores (SD) were 65.4 (22.6) and 64.7 (22.7). We found low hospital admission and mortality rates. EHFScBS scores (-3.6 [-5.7;-1.6]) and PACIC and 5A scores (both 0.5, [0.3;0.7/0.8]) improved in favour of CM but QoL scores showed no significant group differences (Physical/Mental SF-36 summary scores/KCCQ-os [95%CI]: -0.3 [-3.0;2.5]/-0.1 [-3.4;3.1]/1.7 [-3.0;6.4]). CONCLUSIONS In this sample, with little room for improvement regarding evidence-based pharmacotherapy and CHF self-care, case management showed no improved health outcomes or health care utilisation. However, case management significantly improved performance and key intermediate outcomes. Our study provides evidence for the feasibility of the case management model. TRIAL REGISTRATION NUMBER ISRCTN30822978.
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Affiliation(s)
- Frank Peters-Klimm
- Department of General Practice and Health Services Research, University Hospital Heidelberg, Heidelberg, Germany.
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Smeulders ES, Van Haastregt JC, Ambergen T, Uszko-Lencer NH, Janssen-Boyne JJ, Gorgels AP, Stoffers HE, Lodewijks-van der Bolt CL, Van Eijk JT, Kempen GI. Nurse-led self-management group programme for patients with congestive heart failure: randomized controlled trial. J Adv Nurs 2010; 66:1487-99. [DOI: 10.1111/j.1365-2648.2010.05318.x] [Citation(s) in RCA: 84] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Peters-Klimm F, Campbell S, Müller-Tasch T, Schellberg D, Gelbrich G, Herzog W, Szecsenyi J. Primary care-based multifaceted, interdisciplinary medical educational intervention for patients with systolic heart failure: lessons learned from a cluster randomised controlled trial. Trials 2009; 10:68. [PMID: 19678944 PMCID: PMC2736948 DOI: 10.1186/1745-6215-10-68] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2008] [Accepted: 08/13/2009] [Indexed: 12/13/2022] Open
Abstract
Background Chronic (systolic) heart failure (CHF) is a common and disabling condition. Adherence to evidence-based guidelines in primary care has been shown to improve health outcomes. The aim was to explore the impact of a multidisciplinary educational intervention for general practitioners (GPs) (Train the trainer = TTT) on patient and performance outcomes. Methods This paper presents the key findings from the trial and discusses the lessons learned during the implementation of the TTT trial. Primary care practices were randomly assigned to the TTT intervention or to the control group. 37 GPs (18 TTT, 19 control) were randomised and 168 patients diagnosed with ascertained CHF (91 TTT, 77 control) were enrolled. GPs in the intervention group attended four meetings addressing clinical practice guidelines and pharmacotherapy feedback. The primary outcome was patient self-reported quality of life at seven months, using the SF-36 Physical Functioning scale. Secondary outcomes included other SF-36 scales, the Kansas City Cardiomyopathy Questionnaire (KCCQ), total mortality, heart failure hospital admissions, prescribing, depressive disorders (PHQ-9), behavioural change (European Heart Failure Self-Care Behaviour Scale), patient-perceived quality of care (EUROPEP) and improvement of heart failure using NT-proBNP-levels. Because recruitment targets were not achieved an exploratory analysis was conducted. Results There was high baseline achievement in both groups for many outcomes. At seven months, there were no significant mean difference between groups for the primary outcome measure (-3.3, 95%CI -9.7 to 3.1, p = 0.30). The only difference in secondary outcomes related to the prescribing of aldosterone antagonists by GPs in the intervention group, with significant between group differences at follow-up (42 vs. 24%, adjusted OR = 4.0, 95%CI 1.2–13; p = 0.02). Conclusion The intervention did not change the primary outcome or most secondary outcomes. Recruitment targets were not achieved and the under-recruitment of practices and patients alongside a selection bias of participating GPs, prohibit definite conclusions, but the CI indicates a non-effectiveness of the intervention in this sample. We describe the lessons learned from conducting the trial for the future planning and conduct of confirmatory trials in primary care. Trial registration ISRCTN08601529.
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Affiliation(s)
- Frank Peters-Klimm
- Department of General Practice and Health Services Research, University Hospital Heidelberg, Heidelberg, Germany.
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Mårtensson J, Dahlström U, Johansson G, Lernfelt B, Persson H, Willenheimer R. Nurse-Led Heart Failure Follow-Up in Primary Care in Sweden. Eur J Cardiovasc Nurs 2009; 8:119-24. [DOI: 10.1016/j.ejcnurse.2008.10.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2008] [Revised: 09/05/2008] [Accepted: 10/03/2008] [Indexed: 11/25/2022]
Affiliation(s)
- Jan Mårtensson
- Unit of Research and Development in Primary Care, Jönköping, Sweden
- Department of Nursing, School of Health and Sciences, Jönköping, Sweden
| | - Ulf Dahlström
- Department of Cardiology, Linköping University Hospital, Linköping, Sweden
| | | | - Bodil Lernfelt
- Department of Geriatric Medicine, Sahlgrenska University, Göteborg, Sweden
| | - Hans Persson
- Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden
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Khunti K, Stone M, Paul S, Baines J, Gisborne L, Farooqi A, Luan X, Squire I. Disease management programme for secondary prevention of coronary heart disease and heart failure in primary care: a cluster randomised controlled trial. Heart 2007; 93:1398-405. [PMID: 17309907 PMCID: PMC2016933 DOI: 10.1136/hrt.2006.106955] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/02/2007] [Indexed: 11/04/2022] Open
Abstract
AIMS To evaluate the effect of a disease management programme for patients with coronary heart disease (CHD) and chronic heart failure (CHF) in primary care. METHODS A cluster randomised controlled trial of 1316 patients with CHD and CHF from 20 primary care practices in the UK was carried out. Care in the intervention practices was delivered by specialist nurses trained in the management of patients with CHD and CHF. Usual care was delivered by the primary healthcare team in the control practices. RESULTS At follow up, significantly more patients with a history of myocardial infarction in the intervention group were prescribed a beta-blocker compared to the control group (adjusted OR 1.43, 95% CI 1.19 to 1.99). Significantly more patients with CHD in the intervention group had adequate management of their blood pressure (<140/85 mm Hg) (OR 1.61, 95% CI 1.22 to 2.13) and their cholesterol (<5 mmol/l) (OR 1.58, 95% CI 1.05 to 2.37) compared to those in the control group. Significantly more patients with an unconfirmed diagnosis of CHF had a diagnosis of left ventricular systolic dysfunction confirmed (OR 4.69, 95% CI 1.88 to 11.66) or excluded (OR 3.80, 95% CI 1.50 to 9.64) in the intervention group compared to the control group. There were significant improvements in some quality-of-life measures in patients with CHD in the intervention group. CONCLUSIONS Disease management programmes can lead to improvements in the care of patients with CHD and presumed CHF in primary care.
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Affiliation(s)
- Kamlesh Khunti
- Department of Health Sciences, University of Leicester, UK.
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de la Porte PWFBA, Lok DJA, van Veldhuisen DJ, van Wijngaarden J, Cornel JH, Zuithoff NPA, Badings E, Hoes AW. Added value of a physician-and-nurse-directed heart failure clinic: results from the Deventer-Alkmaar heart failure study. Heart 2006; 93:819-25. [PMID: 17065182 PMCID: PMC1994472 DOI: 10.1136/hrt.2006.095810] [Citation(s) in RCA: 85] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
AIM To determine whether an intensive intervention at a heart failure (HF) clinic by a combination of a clinician and a cardiovascular nurse, both trained in HF, reduces the incidence of hospitalisation for worsening HF and/or all-cause mortality (primary end point) and improves functional status (including left ventricular ejection fraction, New York Heart Association (NYHA) class and quality of life) in patients with NYHA class III or IV. SETTING Two regional teaching hospitals in The Netherlands. METHODS 240 patients were randomly allocated to the 1-year intervention (n = 118) or usual care (n = 122). The intervention consisted of 9 scheduled patient contacts-at day 3 by telephone, and at weeks 1, 3, 5, 7 and at months 3, 6, 9 and 12 by a visit-to a combined, intensive physician-and-nurse-directed HF outpatient clinic, starting within a week after hospital discharge from the hospital or referral from the outpatient clinic. Verbal and written comprehensive education, optimisation of treatment, easy access to the clinic, recommendations for exercise and rest, and advice for symptom monitoring and self-care were provided. Usual care included outpatient visits initialized by individual cardiologists in the cardiology departments involved and applying the guidelines of the European Society of Cardiology. RESULTS During the 12-month study period, the number of admissions for worsening HF and/or all-cause deaths in the intervention group was lower than in the control group (23 vs 47; relative risk (RR) 0.49; 95% confidence interval (CI) 0.30 to 0.81; p = 0.001). There was an improvement in left ventricular ejection fraction (LVEF) in the intervention group (plus 2.6%) compared with the usual care group (minus 3.1%; p = 0.004). Patients in the intervention group were hospitalised for a total of 359 days compared with 644 days for those in the usual care group. Beneficial effects were also observed on NYHA classification, prescription of spironolactone, maximally reached dose of beta-blockers, quality of life, self-care behaviour and healthcare costs. CONCLUSION A heart failure clinic involving an intensive intervention by both a clinician and a cardiovascular nurse substantially reduces hospitalisations for worsening HF and/or all-cause mortality and improves functional status, while decreasing healthcare costs, even in a country with a primary-care-based healthcare system.
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