The patient perspective: Quality of life in advanced heart failure with frequent hospitalisations

Trends in heart failure costs for commercially insured patients in the United States (2006-2021)

BACKGROUND

Although prior research has estimated the overarching cost burden of heart failure (HF), a thorough analysis examining medical expense differences and trends, specifically among commercially insured patients with heart failure, is still lacking. Thus, the study aims to examine historical trends and differences in medical costs for commercially insured heart failure patients in the United States from 2006 to 2021.

METHODS

A population-based, cross-sectional analysis of medical and pharmacy claims data (IQVIA PharMetrics® Plus for Academic) from 2006 to 2021 was conducted. The cohort included adult patients (age > = 18) who were enrolled in commercial insurance plans and had healthcare encounters with a primary diagnosis of HF. The primary outcome measures were the average total annual payment per patient and per cost categories encompassing hospitalization, surgery, emergency department (ED) visits, outpatient care, post-discharge care, and medications. The sub-group measures included systolic, diastolic, and systolic combined with diastolic, age, gender, comorbidity, regions, states, insurance payment, and self-payment.

RESULTS

The study included 422,289 commercially insured heart failure (HF) patients in the U.S. evaluated from 2006 to 2021. The average total annual cost per patient decreased overall from $9,636.99 to $8,201.89, with an average annual percentage change (AAPC) of -1.11% (95% CI: -2% to -0.26%). Hospitalization and medication costs decreased with an AAPC of -1.99% (95% CI: -3.25% to -0.8%) and - 3.1% (95% CI: -6.86-0.69%). On the other hand, post-discharge, outpatient, ED visit, and surgery costs increased by an AAPC of 0.84% (95% CI: 0.12-1.49%), 4.31% (95% CI: 1.03-7.63%), 7.21% (95% CI: 6.44-8.12%), and 9.36% (95% CI: 8.61-10.19%).

CONCLUSIONS

The study's findings reveal a rising trend in average total annual payments per patient from 2006 to 2015, followed by a subsequent decrease from 2016 to 2021. This decrease was attributed to the decline in average patient costs within the Medicare Cost insurance category after 2016, coinciding with the implementation of the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015. Additionally, expenses related to surgical procedures, emergency department (ED) visits, and outpatient care have shown substantial growth over time. Moreover, significant differences across various variables have been identified.

Design and baseline characteristics of SALT-HF trial: hypertonic saline therapy in ambulatory heart failure

AIMS

Hypertonic saline solution (HSS) plus intravenous (IV) loop diuretic appears to enhance the diuretic response in patients hospitalized for heart failure (HF). The efficacy and safety of this therapy in the ambulatory setting have not been evaluated. We aimed to describe the design and baseline characteristics of the SALT-HF trial participants.

METHODS AND RESULTS

'Efficacy of Saline Hypertonic Therapy in Ambulatory Patients with HF' (SALT-HF) trial was a multicenter, double-blinded, and randomized study involving ambulatory patients who experienced worsening heart failure (WHF) without criteria for hospitalization. Enrolled patients had to present at least two signs of volume overload, use ≥ 80 mg of oral furosemide daily, and have elevated natriuretic peptides. Patients were randomized 1:1 to treatment with a 1-h infusion of IV furosemide plus HSS (2.6-3.4% NaCl depending on plasmatic sodium levels) versus a 1-h infusion of IV furosemide at the same dose (125-250 mg, depending on basal loop diuretic dose). Clinical, laboratory, and imaging parameters were collected at baseline and after 7 days, and a telephone visit was planned after 30 days. The primary endpoint was 3-h diuresis after treatment started. Secondary endpoints included (a) 7-day changes in congestion data, (b) 7-day changes in kidney function and electrolytes, (c) 30-day clinical events (need of IV diuretic, HF hospitalization, cardiovascular mortality, all-cause mortality or HF-hospitalization).

RESULTS

A total of 167 participants [median age, 81 years; interquartile range (IQR), 73-87, 30.5% females] were randomized across 13 sites between December 2020 and March 2023. Half of the participants (n = 82) had an ejection fraction >50%. Most patients showed a high burden of comorbidities, with a median Charlson index of 3 (IQR: 2-4). Common co-morbidities included diabetes mellitus (41%, n = 69), atrial fibrillation (80%, n = 134), and chronic kidney disease (64%, n = 107). Patients exhibited a poor functional NYHA class (69% presenting NYHA III) and several signs of congestion. The mean composite congestion score was 4.3 (standard deviation: 1.7). Ninety per cent of the patients (n = 151) presented oedema and jugular engorgement, and 71% (n = 118) showed lung B lines assessed by ultrasound. Median inferior vena cava diameter was 23 mm, (IQR: 21-25), and plasmatic levels of N-terminal-pro-B-type natriuretic peptide (NTproBNP) and antigen carbohydrate 125 (CA125) were increased (median NT-proBNP 4969 pg/mL, IQR: 2508-9328; median CA125 46 U/L, IQR: 20-114).

CONCLUSIONS

SALT-HF trial randomized 167 ambulatory patients with WHF and will determine whether an infusion of hypertonic saline therapy plus furosemide increases diuresis and improves decongestion compared to equivalent furosemide administration alone.

TEMPORARY REMOVAL: Opportunities to Improve End-of-Life Care Quality among Patients with Short Terminal Admissions

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Cardioprotective effects of vaccination in hospitalized patients with COVID-19

COVID-19 vaccination has been shown to prevent and reduce the severity of COVID-19 disease. The aim of this study was to explore the cardioprotective effect of COVID-19 vaccination in hospitalized COVID-19 patients. In this retrospective, single-center cohort study, we included hospitalized COVID-19 patients with confirmed vaccination status from July 2021 to February 2022. We assessed outcomes such as acute cardiac events and cardiac biomarker levels through clinical and laboratory data. Our analysis covered 167 patients (69% male, mean age 58 years, 42% being fully vaccinated). After adjustment for confounders, vaccinated hospitalized COVID-19 patients displayed a reduced relative risk for acute cardiac events (RR: 0.33, 95% CI [0.07; 0.75]) and showed diminished troponin T levels (Cohen's d: - 0.52, 95% CI [- 1.01; - 0.14]), compared to their non-vaccinated peers. Type 2 diabetes (OR: 2.99, 95% CI [1.22; 7.35]) and existing cardiac diseases (OR: 4.31, 95% CI [1.83; 10.74]) were identified as significant risk factors for the emergence of acute cardiac events. Our findings suggest that COVID-19 vaccination may confer both direct and indirect cardioprotective effects in hospitalized COVID-19 patients.

Advancements in Heart Transplantation: Donor-Derived Cell-Free DNA as Next-Generation Biomarker

Heart failure, particularly in its advanced stages, significantly impacts quality of life. Despite progress in Guideline-Directed Medical Therapy (GDMT) and invasive treatments, heart transplantation (HT) remains the primary option for severe cases. However, complications such as graft rejection present significant challenges that necessitate effective monitoring. Endomyocardial biopsy (EMB) is the gold standard for detecting rejection, but its invasive nature, associated risks, and healthcare costs have shifted interest in non-invasive techniques. Donor-derived cell-free DNA (dd-cfDNA) has gained attention as a promising non-invasive biomarker for monitoring graft rejection. Compared to EMB, dd-cfDNA detects graft rejection early and enables clinicians to adjust immunosuppression promptly. Despite its advantages, dd-cfDNA testing faces challenges, such as the need for specialized technology and potential inaccuracies due to other clinical conditions. Additionally, dd-cfDNA cannot yet differentiate between types of graft rejection, and its effectiveness in chronic rejection remains unclear. Research is ongoing to set precise standards for dd-cfDNA levels, which would enhance its diagnostic accuracy and help in clinical decisions. The article also points to the future of HT monitoring, which may involve combining dd-cfDNA with other biomarkers and integrating artificial intelligence to improve diagnostic capabilities and personalize patient care. Furthermore, it emphasizes both global and racial inequalities in dd-cfDNA testing and the ethical issues related to its use in transplant medicine.

Differences in Health-Related Quality of Life among Patients with Heart Failure

Heart failure (HF) is characterized by a progressive clinical course marked by frequent exacerbations and repeated hospitalizations, leading to considerably high morbidity and mortality rates. Patients with HF present with a constellation of bothersome symptoms, which range from physical to psychological and mental manifestations. With the transition to more advanced HF stages, symptoms become increasingly more debilitating, interfere with activities of daily living and disrupt multiple domains of life, including physical functioning, psychological status, emotional state, cognitive function, intimate relationships, lifestyle status, usual role activities, social contact and support. By inflicting profuse limitations in numerous aspects of life, HF exerts a profoundly negative impact on health-related quality of life (HRQOL). It is therefore not surprising that patients with HF display lower levels of HRQOL compared not only to the general healthy population but also to patients suffering from other chronic diseases. On top of this, poor HRQOL in patients with HF becomes an even greater concern considering that it has been associated with unfavorable long-term outcomes and poor prognosis. Nevertheless, HRQOL may differ significantly among patients with HF. Indeed, it has consistently been reported that women with HF display poorer HRQOL compared to men, while younger patients with HF tend to exhibit lower levels of HRQOL than their older counterparts. Moreover, patients presenting with higher New York Heart Association (NYHA) functional class (III-IV) have significantly more impaired HRQOL than those in a better NYHA class (I-II). Furthermore, most studies report worse levels of HRQOL in patients suffering from HF with preserved ejection fraction (HFpEF) compared to patients with HF with reduced ejection fraction (HFrEF) or HF with mildly reduced ejection fraction (HFmrEF). Last, but not least, differences in HRQOL have been noted depending on geographic location, with lower HRQOL levels having been recorded in Africa and Eastern Europe and higher in Western Europe in a recent large global study. Based on the observed disparities that have been invariably reported in the literature, this review article aims to provide insight into the underlying differences in HRQOL among patients with HF. Through an overview of currently existing evidence, fundamental differences in HRQOL among patients with HF are analyzed based on sex, age, NYHA functional class, ejection fraction and geographic location or ethnicity.

Remote management of worsening heart failure to avoid hospitalization in a real-world setting

AIMS

From a patient and health system perspective, managing worsening heart failure (WHF) as an outpatient has become a priority. Remote management allows early detection of WHF, enabling timely intervention with the aim of preventing hospitalization. The objective of the study was to evaluate the feasibility and safety of remotely managing WHF events using a multiparametric platform.

METHODS AND RESULTS

All patients enrolled in the heart failure remote management programme of the Bordeaux University Hospital Telemedicine Center between 1 January and 31 December 2021 were included in the study. Follow-up data were collected until 1 March 2022. Inclusion criteria were chronic heart failure (HF) with New York Heart Association ≥II symptoms and an elevated B-type natriuretic peptide (BNP > 100 pg/mL or N-terminal-pro-BNP > 1000 pg/mL). Patient assessments were performed remotely and included measurements of body weight, blood pressure, heart rate, symptoms, biochemical parameters, and data from cardiac implantable electronic devices when available. In total, 161 patients (71 ± 11 years old, 79% male) were followed for a mean of 291 ± 66 days with a mean adherence to the remote monitoring system of 80 ± 20%. Over this period, 52 (32.3%) patients had 105 WHF events, of which 66 (63%) were successfully managed remotely, the remaining requiring hospitalization. Freedom from WHF events and hospitalization at 300 days were 66% and 85%, respectively (P < 0.001 for the difference). Increased level of BNP was associated with an increased risk of WHF event [hazard ratio (HR) per unit increase in BNP: 1.001; 95% confidence interval (CI) 1-1.002; P = 0.001] and hospitalization (HR 1.002; 95% CI 1.002-1.003; P = 0.002). A decrease in the level of glomerular filtration rate was associated with an increased risk of hospitalization (HR per unit decrease in estimated glomerular filtration rate: 0.946; 95% CI 0.906-0.989; P = 0.014). WHF event recurrence and (re)hospitalization rates at 1-month were similar among patients managed remotely (18% and 12%, respectively) and those requiring hospitalization (21% and 10%, respectively). Iatrogenic complications occurred more often during hospitalization than remote management (26% vs. 3%, P < 0.001).

CONCLUSIONS

Our study suggests that remote management of WHF events based on a multiparametric approach led by a telemedical centre is feasible and safe. Adopting such a strategy for patients with chronic HF could reduce HF-related hospitalizations with expected benefits for patients, care providers, and health care systems.

Depression, anxiety, and quality of life as predictors of rehospitalization in patients with chronic heart failure

BACKGROUND

Chronic heart failure (CHF) is a severe condition, often co-occurring with depression and anxiety, that strongly affects the quality of life (QoL) in some patients. Conversely, depressive and anxiety symptoms are associated with a 2-3 fold increase in mortality risk and were shown to act independently of typical risk factors in CHF progression. The aim of this study was to examine the impact of depression, anxiety, and QoL on the occurrence of rehospitalization within one year after discharge in CHF patients.

METHODS

148 CHF patients were enrolled in a 10-center, prospective, observational study. All patients completed two questionnaires, the Hospital Anxiety and Depression Scale (HADS) and the Questionnaire Short Form Health Survey 36 (SF-36) at discharge timepoint.

RESULTS

It was found that demographic and clinical characteristics are not associated with rehospitalization. Still, the levels of depression correlated with gender (p ≤ 0.027) and marital status (p ≤ 0.001), while the anxiety values ​​were dependent on the occurrence of chronic obstructive pulmonary disease (COPD). However, levels of depression (HADS-Depression) and anxiety (HADS-Anxiety) did not correlate with the risk of rehospitalization. Univariate logistic regression analysis results showed that rehospitalized patients had significantly lower levels of Bodily pain (BP, p = 0.014), Vitality (VT, p = 0.005), Social Functioning (SF, p = 0.007), and General Health (GH, p = 0.002). In the multivariate model, poor GH (OR 0.966, p = 0.005) remained a significant risk factor for rehospitalization, and poor General Health is singled out as the most reliable prognostic parameter for rehospitalization (AUC = 0.665, P = 0.002).

CONCLUSION

Taken together, our results suggest that QoL assessment complements clinical prognostic markers to identify CHF patients at high risk for adverse events.

CLINICAL TRIAL REGISTRATION

The study is registered under http://clinicaltrials.gov (NCT01501981, first posted on 30/12/2011), sponsored by Charité - Universitätsmedizin Berlin.

Spot Urinary Creatinine Concentration in Patients with Chronic Heart Failure Identifies a Distinct Muscle-Wasting Phenotype with a Strikingly Different Risk of Mortality

BACKGROUND

There is a raising awareness that heart failure (HF) is a highly heterogeneous, multiorgan syndrome with an increasing global prevalence and still poor prognosis. The comorbidities of HF are one of the key reasons for presence of various phenotypes with different clinical profile and outcome. Heterogeneity of skeletal muscles (SMs) quantity and function may have an impact on patient's phenotype.

AIM

We intended to compare clinical characteristics of phenotypes defined by a combination of various SM mass taken as a fat-free compartment from DEXA scans and different levels of SUCR (Spot Urinary Creatinine). All-cause mortality with mortality predicted by MAGGIC in such phenotypes were compared.

METHODS

In 720 HF patients with reduced ejection fraction (age: 52.3 ± 10 years, female: 14%, NYHA: 2.7 ± 0.7, LVEF: 24.3 ± 7.3%), admitted to the hospital for heart transplantation candidacy assessment, morning SUCR along with body composition scanning (DEXA) was performed. All study participants were dichotomized twice, first by low or normal appendicular muscle mass index (ASMI) and second by SUCR (Spot Urinary Creatinine) < and ≥of 1.34 g/L. Four study groups (phenotypes) were created as combinations of lower or higher SUCR and low or normal ASMI.

RESULTS

Low ASMI was found in 242 (33.6%) patients, while the remaining 478 had normal muscle mass. In 446 patients (61.9%), SUCR was <1.34 g/L. During 3 years of follow-up, 223 (31.0%) patients died (all-cause). The phenotype of lower both ASMI and SUCR was associated with the highest mortality. The death rate in phenotype with both low ASMI and SUCR exceeded by 70% the risk estimated by MAGGIC. This difference was significant as judged by the 95% confidence interval for MAGGIC estimation. In Cox regression analysis adjusted for MAGGIC and parameters known to increase risk, the relative risk of patients with phenotype of low both ASMI and SUCR was elevated by 45-55% as compared to patients with all other phenotypes. The protective role of higher SUCR in patients with muscle wasting was, therefore, confirmed in Cox analysis.

CONCLUSIONS

Measurement of SUCR in HF patients can identify clinical phenotypes with skeletal muscle wasting but strikingly different risk of death that is actually not captured by MAGGIC score. The higher level of SUCR was associated with similar risk independently of presence of muscle wasting. As the analysis of SUCR is cheap and easy to perform, it should be further tested as a potentially useful biomarker, which may precisely phenotype HF patients independently of their skeletal muscle status.

Quality of life among patients with supraventricular tachycardia post radiofrequency cardiac ablation in Jordan

BACKGROUND

Supraventricular tachycardia (SVT) is a common arrhythmia with associated symptoms such as palpitation, dizziness, and fatigue. It significantly affects patients' quality of life (QoL). Radiofrequency cardiac ablation (RFCA) is a highly effective treatment to eliminate arrhythmia and improve patients' QoL. The purpose of this study was to assess the level of QoL among patients with SVT and examine the difference in QoL before and after RFCA.

METHODS

One group pre-posttest design with a convenience sample of 112 patients was used. QoL was assessed by 36-Item Short Form (SF-36). Data were collected at admission through face-to-face interviews and 1-month post-discharge through phone interviews.

RESULTS

There was a significant difference between QoL before (33.7±17.0) and 1 month after (62.5±18.5) the RFCA. Post-RFCA patients diagnosed with atrioventricular nodal reentrant tachycardia had higher QoL than other types of SVT. Moreover, there were significant negative relationships between QoL and the number and duration of episodes pre- and post-RFCA. There were no significant differences in QoL based on: age, sex, working status, marital status, smoking, coronary artery disease, diabetes mellitus, and hypertension.

CONCLUSIONS

After RFCA, the QoL of patients with ST improved for both physical and mental component subscales.

Challenges and opportunities for increasing patient involvement in heart failure self-care programs and self-care in the post-hospital discharge period

BACKGROUND

People living with heart failure (HF) are particularly vulnerable after hospital discharge. An alliance between patient authors, clinicians, industry, and co-developers of HF programs can represent an effective way to address the unique concerns and obstacles people living with HF face during this period. The aim of this narrative review article is to discuss challenges and opportunities of this approach, with the goal of improving participation and clinical outcomes of people living with HF.

METHODS

This article was co-authored by people living with HF, heart transplant recipients, patient advocacy representatives, cardiologists with expertise in HF care, and industry representatives specializing in patient engagement and cardiovascular medicine, and reviews opportunities and challenges for people living with HF in the post-hospital discharge period to be more integrally involved in their care. A literature search was conducted, and the authors collaborated through two virtual roundtables and via email to develop the content for this review article.

RESULTS

Numerous transitional-care programs exist to ease the transition from the hospital to the home and to provide needed education and support for people living with HF, to avoid rehospitalizations and other adverse outcomes. However, many programs have limitations and do not integrally involve patients in the design and co-development of the intervention. There are thus opportunities for improvement. This can enable patients to better care for themselves with less of the worry and fear that typically accompany the transition from the hospital. We discuss the importance of including people living with HF in the development of such programs and offer suggestions for strategies that can help achieve these goals. An underlying theme of the literature reviewed is that education and engagement of people living with HF after hospitalization are critical. However, while clinical trial evidence on existing approaches to transitions in HF care indicates numerous benefits, such approaches also have limitations.

CONCLUSION

Numerous challenges continue to affect people living with HF in the post-hospital discharge period. Strategies that involve patients are needed, and should be encouraged, to optimally address these challenges.

Exercise capacity and its determinants among postcardiac rehabilitation patients with coronary heart disease

AIM

To investigate the determinants of exercise capacity in postcardiac rehabilitation patients with coronary heart disease (CHD).

DESIGN

A cross-sectional design was used.

METHODS

This study analysed the cross-sectional data from the baseline assessment of 130 CHD patients who participated in a longitudinal randomized controlled trial of music-paced physical activity intervention for CHD patients (ChiCTR-IOR-17011015) (September 2017 to February 2019). Exercise capacity was measured by using the 10-metre incremental shuttle-walk test. The amount of physical activity, exercise self-determination and exercise self-efficacy were measured by validated instruments. Participants' anthropometric parameters (body mass index, body fat mass percentage and waist circumference) were measured. Hierarchical regression analyses were used to identify the factors influencing exercise capacity.

RESULTS

The mean incremental shuttle-walk test distance was 493.00 ± 180.04 m. The factors significantly associated with exercise capacity were age (β = -.42), female (β = -.35), body mass index (β = -.25) and exercise self-efficacy (β = -.20). These factors accounted for 56.5% of the total variance of exercise capacity.

Clinical and economic impact of ferric carboxymaltose treatment for iron deficiency in patients stabilized following acute heart failure: a multinational study

OBJECTIVE

To estimate clinical events and evaluate the financial implications of introducing ferric carboxymaltose (FCM) to treat iron deficiency (ID) at discharge in patients hospitalized for acute heart failure (AHF) with left ventricular ejection fraction (LVEF) <50% in the UK, Switzerland and Italy.

METHODS

A decision analytic cost-offset model was developed to evaluate the costs associated with introducing FCM for all eligible patients in three countries compared to a world without FCM, over a five-year time horizon. Data from AFFIRM-AHF clinical trial were used to model clinical outcomes, using an established cohort state-transition Markov model. Country-specific prevalence estimates were derived using data from real-world studies to extrapolate number of events and consequent cost totals to the population at risk on a national scale.

RESULTS

The cost-offset modeling demonstrated that FCM is projected to be a cost-saving intervention in all three country settings over a five-year time horizon. Savings were driven primarily by reduced hospitalizations and avoided cardiovascular deaths, with net cost savings of -£14,008,238, -CHF25,456,455 and -€105,295,146 incurred to the UK, Switzerland and Italy, respectively.

LIMITATIONS

Although AFFIRM-AHF was a multinational trial, efficacy data per country was not sufficiently large to enable country-specific analysis, therefore overall clinical parameters have been assumed to apply to all countries.

CONCLUSIONS

This study provides further evidence of the potential cost savings achievable by treating ID with FCM at discharge in patients hospitalized for AHF with LVEF <50%. The value of FCM treatment within the healthcare systems of the UK, Switzerland and Italy was demonstrated even within a limited time frame of one year, with consistent cost savings indicated over a longer term.

Development and appropriateness of a scoring method for International Classification of Functioning, Disabilities, and Health assessment in older patients with heart failure: a Delphi survey of expert panel in Japan

OBJECTIVE

The number of older patients with heart failure (HF) is increasing in Japan and has become a social problem. There is an urgent need to develop a comprehensive assessment methodology based on the common language of healthcare; the International Classification of Functioning, Disability and Health (ICF). The purpose of this study was to develop and confirm the appropriateness of a scoring methodology for 43 ICF categories in older people with HF.

DESIGN

Cross-sectional survey. We applied the RAND/University of California at Los Angeles (UCLA) Appropriateness Method with a modified Delphi method.

SETTING AND PARTICIPANTS

We included a panel of 26 multidisciplinary experts on HF care consisting of home physicians, cardiovascular physicians, care managers, nurses, physical therapists, a pharmacist, occupational therapist, nutritionist and a social worker.

MEASURES

We conducted a literature review of ICF linking rules and developed a questionnaire on scoring methods linked to ICF categories in older people with HF. In the Delphi rounds, we sent the expert panel a questionnaire consisting of three questions for each of the 43 ICF categories. The expert panel responded to the questionnaire items on a 1 (very inappropriate) - 9 (very appropriate) Likert scale and repeated rounds until a consensus of 'Appropriate' and 'Agreement' was reached on all items.

RESULTS

A total of 21 panel members responded to all the Delphi rounds. In the first Delphi round, six question items in four ICF categories did not reach a consensus of 'Agreement', but the result of our modifications based on panel members' suggestions reached to a consensus of 'Appropriate' and 'Agreement' on all questions in the second Delphi round.

CONCLUSION

The ICF-based scoring method for older people with HF developed in this study was found to be appropriate. Future work is needed to clarify whether comprehensive assessment and information sharing based on ICF contributes to preventing readmissions.

Frontiers and Hotspots Evolution in Psycho-cardiology: A Bibliometric Analysis From 2004 to 2022

In the last 20 years, research on the topic of psycho-cardiology has gradually entered the public eye, with more innovations and applications of evidence-based medical research, biological mechanism research, and guideline consensus in the field of psycho-cardiology. This study uses a bibliometric approach to visualize and analyze the literature within the field of psycho-cardiology over the last 20 years to visualize the development process, research hotspots, and cutting-edge trends in clinical practice, mechanisms, and management strategies related to psycho-cardiology. Quantitative description and evaluation of 409 articles published in the field from 2004-2022 were conducted using CiteSpace and VOSviewer, to provide a theoretical reference for the development of psycho-cardiology.

Association of Repetitive Dosing of Levosimendan with Reduction of NYHA Class and NT-proBNP Levels in Decompensated Heart Failure: A Retrospective Cohort Study

Background

There is evidence that repetitive administration of levosimendan can improve outcome in chronic heart failure patients.

Objective

The aim of this retrospective study was to investigate the effect of therapy with levosimendan (LEV) additional to standard medical care in patients with symptomatic heart failure (HFrEF = heart failure with reduced ejection fraction) on NYHA class, NT-proBNP values, ejection fraction (EF) and body weight.

Patients and Methods

178 participating patients (125 male, 53 female; mean age of 73 ± 13 years) were grouped according to whether LEV was given once (group 1) or repetitively (group 2). In group 2 data were analysed for first treatment with LEV (group 2a) and for the following repetitive LEV treatments (group 2b). The differentiation was required to see if there were different results for the particular groups.

Results

Repetitive dosing was given between two and 11 times, leading to 47 repetitive applications of LEV and a total of 225 (178 once + 47 repetitive) applications. The mean time between the repetitive dosing was 133 days or 4.3 months. LEV in addition to standard medical treatment was associated with reduction of NT-proBNP levels from 9138 to 7051 pg/mL (p < 0.05). The corresponding values in group 2a and group 2b were 8790–4717 pg/mL (p < 0.05) as well as 13,681–7581 pg/mL (p < 0.05). The ejection fraction measured by echocardiography improved from 30 to 38% in group 1, from 31 to 45% in group 2a and from 30 to 35% in group 2b (p < 0.05). Addition of LEV was associated with significant reduction of NYHA class and bodyweight in all groups. No adverse side effects (e.g., rhythm disorder, hypotension, electrolyte disorder) were seen.

Conclusion

LEV may be useful as an additive to standard care of treatment for patients with acute de novo decompensation due to acute heart failure as well as to prevent further deterioration in patients with chronic heart failure disease at high risk for hospitalisation. Intraindividual changes in NT-proBNP levels may be useful in decision-making about the need for additional treatment options in patients with worsening heart failure.

In-hospital electrical muscle stimulation for patients early after heart failure decompensation: results from a prospective randomised controlled pilot trial

Background

Electrical muscle stimulation (EMS) is being evaluated as a possible alternative to exercise training to improve functional capacity in severely deconditioned patients with heart failure (HF). However, there is insufficient data on delayed effects of EMS starting early after decompensation. The aim of this study was to determine the impact of a short inpatient EMS intervention in severely deconditioned patients with HF on functional capacity and quality of life (QoL) over a follow-up period of 1 month.

Methods

This is a prospective randomised sham-controlled pilot study. 45 patients hospitalised for decompensated systolic HF (58% men, mean age 66.4±10.2 years) were randomised to EMS (n=22) or sham stimulation (n=23) of lower limbs starting within 3 days after admission. The intervention included 7–10 sessions lasting from 30 to 90 min. The 6-minute walking test distance (6-MWTD), Duke Activity Status Index (DASI) and Minnesota Living with Heart Failure Questionnaire (MLHFQ) were evaluated at baseline, discharge and after 1 month.

Results

All patients completed the programme with good EMS tolerance. 37 patients were included in the final analysis. At discharge, 6-MWTD improved from 206,1±61,3 to 299.5±91 m, DASI from 12.1±5.6 to 18.3±7.2 and MLHFQ from 55.6±8.5 to 34.2±9 with EMS compared with smaller improvements in the sham group (p<0.05 for all). One month after discharge, improvements in the EMS group remained significant for MLHFQ (p=0.004) and DASI (p=0.042) and statistically non-significant for 6-MWTD compared with the sham group.

Conclusions

Short-term in-hospital EMS leads to improvements in functional capacity and QoL in selected patients early after HF decompensation that are retained over 1 month after discharge and therefore may serve as initial intervention to improve physical capacity or as a bridge to further conventional exercise training. Larger studies are required to evaluate individual responses to an early initiation of EMS in decompensated HF as well as long-term effects.

Patients' knowledge and concerns about using the implantable cardioverter defibrillator for the primary prevention of sudden cardiac death and its correlates: A cross‐sectional study

Background and Aims

Methods

Results

Conclusion

Needs and problems related to sociodemographic factors of informal caregiving of people with heart failure: A mixed methods study in three European countries

AIMS

To explore caregivers' needs and problems in three European countries and associate the clusters of caregivers' needs with their sociodemographic characteristics.

DESIGN

A qualitative focused mixed methods design was used.

METHODS

In total, 52 caregivers of heart failure (HF) people were interviewed in three European countries between March 2017 and December 2018. Transcripts were analysed using the seven-phase method of the exploratory multidimensional analysis according to Fraire with Reinert lexical classes findings were organized in dendrograms. Mayring's content analysis was also performed.

RESULTS

Three clusters of caregivers were identified: spouses, adult children and non-family members. Caregivers not only provide HF patients with vital unpaid support for their physical and emotional needs, but they are continually trying to cope with their social isolation and deteriorating health.

CONCLUSIONS

Informal caregiving emerged as a complex process influenced by various sociodemographic factors. Gender, relationship type and economic status are the important factors to be considered planning to develop approaches to address the needs of caregivers serving people with heart failure.

IMPACT

A comprehensive understanding of the nature of informal caregiving of individuals with heart failure, the complexity of the real-world sociodemographic and cultural factors is warranted. The use of the EMDA method gave us the possibility of processing large masses of qualitative data through rapid, complex calculations. In detail, AATD allowed us to study in deep the significant fuzziness of what caregivers expressed and to analyse the content of the entire interviews and to produce global knowledge by using multi-dimensional statistical methods to grasp the fundamental sense of the interviews, beyond the simple words. Three clusters were identified in the samples, including spouses, adult children and non-family members. This study demonstrated that some sociodemographic characteristics could lead to everyday needs. Therefore, these demographic characteristics should be considered in developing targeted interventions. The research was conducted in Europe, but the technique shown can be replicated everywhere. The findings not only impact nursing but can be extended to all those stakeholders who concur with a public health educational mission.

PATIENT OR PUBLIC CONTRIBUTION

Carers were involved in this study after the discharge of their loved ones or at the time of the outpatient visit. They were involved after they had been observed in their dynamics of involvement in caring of the familiars or friends with heart failure.

Use of CIED Generated Heart Failure Risk Score (HFRS) Alerts in an Integrated, Multi-Disciplinary Approach to HF Management-A Prospective Cohort Study

Aim: To evaluate use of CIED-generated Heart Failure Risk Score (HFRS) alerts in an integrated, multi-disciplinary approach to HF management. Methods: We undertook a prospective, single centre outcome study of patients implanted with an HFRS-enabled Medtronic CIED, generating a “high risk” alert between November 2018 and November 2020. All patients generating a “high risk” HFRS alert were managed within an integrated HF pathway. Alerts were shared with local HF teams, prompting patient contact and appropriate intervention. Outcome data on health care utilisation (HCU) and mortality were collected. A validated questionnaire was completed by the HF teams to obtain feedback. Results: 367 “High risk” alerts were noted in 188 patients. The mean patient age was 70 and 49% had a Charlson Comorbidity Score of >6. Mean number of alerts per patients was 1.95 and 44 (23%) of patients had >3 “high risk” alerts in the follow up period. Overall, 75 (39%) patients were hospitalised in the 4−6-week period of the alert; 53 (28%) were unplanned of which 24 (13%) were for decompensated HF. A total of 33 (18%) patients died in the study period. Having three or more alerts significantly increased the risk of hospitalisation for heart failure (HR 2.5, CI 1.1−5.6 p = 0.03). The feedback on the pathway was positive. Conclusions: Patients with “high risk” alerts are co-morbid and have significant HCU. An integrated approach can facilitate timely risk stratification and intervention. Intervention in these patients is not limited to HF alone and provides the opportunity for holistic management of this complex cohort.

Psychometric Validation of the Korean Version of the Heart Failure-Specific Health Literacy Scale

BACKGROUND AND PURPOSE

The goals of heart failure (HF) management include lowering adverse outcomes through optimal self-care. Health literacy has a significant role in ensuring optimal and effective HF self-care. Unfortunately, the proportion of low health literacy in HF patients is higher than those with other chronic diseases as well as the general population. Thus, healthcare providers need to screen HF patients. The HF-Specific Health Literacy Scale is a specific questionnaire to screen the health literacy in HF patients; however, the Korean version has not yet been validated. The study aimed to investigate the reliability and validity of the Korean version of the HF-Specific Health Literacy Scale.

METHODS

We adopted a cross-sectional study design with 386 outpatients with chronic HF from a tertiary care hospital in Cheonan, South Korea. Data were collected from April to December 2020.

RESULTS

The exploratory factor analysis revealed a three-factor (functional, communicative, and critical health literacy) 12-item structure of the scale. The result of the confirmatory factor analysis confirmed a good statistical fit for the data. The Korean version of the tool demonstrated satisfactory convergent and discriminant validity. The criterion validity analysis revealed significant correlation with general health literacy and knowledge about HF. The Korean version of the tool for 12 items had adequate overall internal consistency.

IMPLICATIONS FOR PRACTICE

The Korean version of the HF-Specific tool can be easily utilized for assessing health literacy level for HF patient education. Moreover, the tool can help healthcare providers develop strategies for promoting HF patients' health literacy.

Impact of Melatonin and Branched-Chain Amino Acids Cosupplementation on Quality of Life, Fatigue, and Nutritional Status in Cachectic Heart Failure Patients: A Randomized Controlled Trial

Background: Cardiac cachexia (CC) adversely affects the lifestyle of heart failure (HF) patients. The current study examined the impact of melatonin cosupplementation and branched-chain amino acids (BCAAs) on quality of life (QoL), fatigue, and nutritional status in cachectic HF patients. Methods: In this trial, 84 CC patients were randomized to melatonin, BCAAs, or coadministration (both) as intervention groups and a control group over 8 weeks. At baseline and postintervention, QoL, fatigue, and nutritional status were assessed. Results: After intervention, improvement in the overall and physical dimensions of QoL and appetite score were found to be statistically significant in the BCAAs (P < .001) and the melatonin+BCAAs (P < .001) groups compared with the placebo group. The emotional dimension score was significantly lower in the BCAAs group compared with the placebo group (P = .001). There was a statistically significant improvement in fatigue severity in all 3 intervention groups compared with the placebo group. The nutrition risk index (NRI) score increased significantly only in the melatonin group (P = .015), and there was no significant difference between the other groups (P = .804). Conclusions: Cosupplementation with BCAAs and melatonin improved QoL, fatigue status, and appetite in cachectic HF patients but did not affect NRI.

Application value of myocardial work technology by non-invasive echocardiography in evaluating left ventricular function in patients with chronic heart failure

BACKGROUND

Accurate evaluation of left ventricular (LV) systolic function is the premise for diagnosing and treating chronic heart failure. This study aimed to explore the incremental value of echocardiographic myocardial work in evaluating the LV systolic dysfunction in patients with chronic heart failure.

METHODS

A total of 206 participants were enrolled, including 155 patients with chronic heart failure and 51 healthy controls (HC). The chronic heart failure patients were divided into three groups according to LV ejection fraction (LVEF): Heart failure with preserved ejection fraction (HFpEF group, 54 cases, LVEF ≥50%), heart failure with mid-range ejection fraction (HFmrEF group, 50 cases, 40%≤ LVEF <50%), and heart failure with reduced ejection fraction (HFrEF group, 51 cases, LVEF <40%). Except for the conventional echocardiographic parameters, the left ventricular myocardial work parameters, including the global myocardial work index (GWI), global constructive work (GCW), global wasted work (GWW), and global work efficiency (GWE), were calculated in the study participants. One-way analysis of variance test followed by Fisher's least significant difference (LSD) t-test were used to obtain parameters with significant differences, which were then fed into a machine learning model established for subsequent multi-classification of the four groups. The selected myocardial work parameters with high importance rankings resulting from the machine learning model were further compared with the traditional LVEF in the multi-classification of the four groups.

RESULTS

All conventional echocardiographic parameters were significantly different between the HFmrEF and HFrEF groups, but only E/e', left atrium showed notable differences between the HFpEF and HC groups (P<0.05). All myocardial work parameters were markedly different between the four groups (P<0.05). LVEF and GWI were more important than the other parameters according to the multi-classification machine learning model. The multi-classification diagnostic performances of LVEF, GWI, and LVEF + GWI were 82%, 88%, and 98%, respectively, which confirmed that GWI + LVEF could complementarily improve the diagnosis accuracy in classifying the four groups, with a performance increase of approximately 10% than each individually.

CONCLUSIONS

GWI can play a complementary role to LVEF in the early diagnosis of HFpEF patients from the HC group and improve the clinical evaluation accuracy in chronic heart failure patients. Echocardiographic myocardial work should be utilized along with conventional LVEF to evaluate the systolic function of chronic heart failure patients in clinical practice.

The International Classification of Functioning, Disabilities, and Health categories rated as necessary for care planning for older patients with heart failure: a survey of care managers in Japan

BACKGROUND

Establishing an information-sharing system between medical professionals and welfare/care professionals may help prevent heart failure (HF) exacerbations in community-dwelling older adults. Therefore, we aimed to identify the ICF categories necessary for care managers to develop care plans for older patients with HF.

METHODS

A questionnaire was administered to 695 care managers in Hiroshima, Japan, on ICF items necessary for care planning. We compared the care managers according to their specialties (medical qualifications and welfare or care qualifications). Furthermore, we created a co-occurrence network using text mining, regarding the elements necessary for collaboration between medical and care professionals.

RESULTS

There were 520 valid responses (74.8%). Forty-nine ICF items, including 18 for body functions, one for body structure, 21 for activities and participation, and nine for environmental factors, were classified as "necessary" for making care plans for older people with HF. Medical professionals more frequently answered "necessary" than care professionals regarding the 11 items for body functions and structure and three items for activities and participation (p < 0.05). Medical-welfare/care collaboration requires (1) information sharing with related organisations; (2) emergency response; (3) a system of cooperation between medical care and non-medical care; (4) consultation and support for individuals and families with life concerns, (5) management of nutrition, exercise, blood pressure and other factors, (6) guidelines for consultation and hospitalisation when physical conditions worsen.

CONCLUSIONS

Our findings showed that 49 ICF categories were required by care managers for care planning, and there was a significant difference in perception between medical and welfare or care qualifications qualifications.

Quality of life and disease experience in patients with heart failure with reduced ejection fraction in Spain: a mixed-methods study

OBJECTIVES

To gather insights on the disease experience of patients with heart failure (HF) with reduced ejection fraction (HFrEF), and assess how patients' experiences and narratives related to the disease complement data collected through standardised patient-reported outcome measures (PROMs). Also, to explore new ways of evaluating the burden experienced by patients and caregivers.

DESIGN

Observational, descriptive, multicentre, cross-sectional, mixed-methods study.

SETTING

Secondary care, patient's homes.

PARTICIPANTS

Twenty patients with HFrEF (New York Heart Association (NYHA) classification I-III) aged 38-85 years.

MEASURES

PROMs EuroQoL 5D-5L (EQ-5D-5L) and Kansas City Cardiomyopathy Questionnaire and patient interview and observation.

RESULTS

A total of 20 patients with HFrEF participated in the study. The patients' mean (SD) age was 72.5 (11.4) years, 65% were male and were classified inNYHA functional classes I (n=4), II (n=7) and III (n=9). The study showed a strong impact of HF in the patients' quality of life (QoL) and disease experience, as revealed by the standardised PROMs (EQ-5D-5L global index=0.64 (0.36); Kansas City Cardiomyopathy Questionnaire total symptom score=71.56 (20.55)) and the in-depth interviews. Patients and caregivers often disagreed describing and evaluating perceived QoL, as patients downplayed their limitations and caregivers overemphasised the poor QoL of the patients. Patients related current QoL to distant life experiences or to critical moments in their disease, such as hospitalisations. Anxiety over the disease progression is apparent in both patients and caregivers, suggesting that caregiver-specific tools should be developed.

CONCLUSIONS

PROMs are an effective way of assessing symptoms over the most recent time period. However, especially in chronic diseases such as HFrEF, PROM scores could be complemented with additional tools to gain a better understanding of the patient's status. New PROMs designed to evaluate and compare specific points in the life of the patient could be clinically more useful to assess changes in health status.

Efficacy and safety of intermittent repeated levosimendan infusions in advanced heart failure patients: the LAICA study

Aims

The aim of the LAICA study was to evaluate the long‐term effectiveness and safety of intermittent levosimendan infusion in patients with advanced heart failure (AdHF).

Methods and results

This was a multicentre, randomized, double‐blind, placebo‐controlled clinical trial of intermittent levosimendan 0.1 μg/kg/min as a continuous 24‐h intravenous infusion administered once monthly for 1 year in patients with AdHF. The primary endpoint [incidence of rehospitalization (admission to the emergency department or hospital ward for >12 h) for acute decompensated HF or clinical deterioration of the underlying HF] occurred in 23/70 (33%) of the levosimendan group (Group I) and 12/27 (44%) of the placebo group (Group II) (P = 0.286). The incidence of hospital readmissions for acute decompensated HF (Group I vs. Group II) at 1, 3, 6, and 12 months was 4.2% vs. 18.2% (P = 0.036); 12.8% vs. 33.3% (P = 0.02); 25.7% vs. 40.7% (P = 0.147); 32.8% vs. 44.4% (P = 0.28), respectively. In a secondary pre‐specified time‐to‐event analysis no differences were observed in admission for acute decompensated HF between patients treated with levosimendan compared with placebo (hazard ratio 0.66; 95% CI, 0.32–1.32; P = 0.24). Cumulative incidence for the aggregated endpoint of acute decompensation of HF and/or death at 1 and 3 months were significatively lower in the levosimendan group than in placebo group [5.7% vs. 25.9% (P = 0.004) and 17.1% vs. 48.1% (P = 0.001), respectively], but not at 6 and 12 months [34.2% vs. 59.2% (P = 0.025); 41.4% vs. 66.6% (P = 0.022), respectively]. Survival probability was significantly higher in patients who received levosimendan compared with those who received placebo (log rank: 4.06; P = 0.044). There were no clinically relevant differences in tolerability between levosimendan and placebo and no new safety signals were observed.

Conclusions

In our study, intermittent levosimendan in patients with AdHF produced a statistically non‐significant reduction in the incidence of hospital readmissions for acute decompensated HF, a significantly lower cumulative incidence of acute decompensation of HF and/or death at 1 and 3 month of treatment and a significant improvement in survival during 12 months of treatment.

Haemodynamic Effects of Levosimendan in Outpatients with Advanced Heart Failure: An Echocardiographic Pilot Study

ABSTRACT

Infusions of levosimendan delivered in ambulatory/outpatient settings have been shown to improve quality of life and reduce hospitalizations in patients with advanced heart failure. The aim of this study was to evaluate the effects of ambulatory infusion of levosimendan on echocardiographic markers of perfusion, congestion, and cardiovascular efficiency.Thirty patients with diagnosed advanced HF underwent ambulatorial infusion of levosimendan. Standardized transthoracic echocardiography, Doppler examinations, and strain analysis were performed 1 h before and 48 h after completion of ambulatory infusion of 6,25 mg of levosimendan. At 48 h after ambulatory infusion of levosimendan, a significant increase in the stroke volume (37.47 ± 12.38 mL/beat vs 45.47 ± 14.48 mL/beat; p < 0.05) and cardiac output (2.64 ± 0.66 L/min vs 3.26 ± 0.57 L/min; p < 0.05) occurred. Significant post-versus-pre reductions were also recorded in left atrial pressure (27.37 ± 6.62 mmHg vs 22.82 ± 4.17 mmHg; p < 0.01); mean pulmonary artery pressure (27.69 ± 4.64 mmHg vs 23.24 ± 5.32; p < 0.01); and inferior vena cava diameter (23.81 ± 7.63 mm vs 18.53 ± 4.82 mm; p < 0.01) occurred. Significant improvements were noted in the resting cardiac power output (0.46 ± 0,15watt vs 0.53 ± 0.22 watt; p < 0.01) and the resting cardiac power index (0.24 ± 0.08 watt/m2 vs 0.28 ± 0.11 watt/m2; p < 0.01).In outpatients with advanced HF infusion of levosimendan was associated with hemodynamic responses that may contribute to the clinical benefit previously reported in such patients.

Association between high cost user status and end-of-life care in hospitalized patients: A national cohort study of patients who die in hospital

BACKGROUND

Studies comparing end-of-life care between patients who are high cost users of the healthcare system compared to those who are not are lacking.

AIM

The objective of this study was to describe and measure the association between high cost user status and several health services outcomes for all adults in Canada who died in acute care, compared to non-high cost users and those without prior healthcare use.

SETTINGS AND PARTICIPANTS

We used administrative data for all adults who died in hospital in Canada between 2011 and 2015 to measure the odds of admission to the intensive care unit (ICU), receipt of invasive interventions, major surgery, and receipt of palliative care during the hospitalization in which the patient died. High cost users were defined as those in the top 10% of acute healthcare costs in the year prior to a person's hospitalization in which they died.

RESULTS

Among 252,648 people who died in hospital, 25,264 were high cost users (10%), 112,506 were non-high cost users (44.5%) and 114,878 had no prior acute care use (45.5%). After adjustment for age and sex, high cost user status was associated with a 14% increased odds of receiving an invasive intervention, a 15% increased odds of having major surgery, and an 8% lower odds of receiving palliative care compared to non-high cost users, but opposite when compared to patients without prior healthcare use.

CONCLUSIONS

Many patients receive aggressive elements of end-of-life care during the hospitalization in which they die and a substantial number do not receive palliative care. Understanding how this care differs between those who were previously high- and non-high cost users may provide an opportunity to improve end of life care for whom better care planning and provision ought to be an equal priority.

Web-Based Training and Telephone Follow-up of Patients With Heart Failure: Randomized Controlled Trial

This study was carried out to determine the effect of Web-based training and telephone follow-up on symptom burden and health status in patients with heart failure. Patient training and postdischarge follow-up are necessary to improve symptom management and quality of life in patients with heart failure. In Turkey, Web-based education and phone monitoring are not very common yet. In this parallel randomized controlled trial, patients were allocated to a control group (n = 32) or an intervention group (n = 32). The control group received routine care, and the intervention group was administered the following interventions in addition to routine care: Web-based training, four-session telephone follow-up, and one text message weekly. All results regarding symptom management and quality of life were assessed beginning and at the 12th week. The Consolidated Standards of Reporting Trials checklist was used. In the 12th week after discharge, patients in the intervention group showed a significant improvement in terms of symptom burden and health status compared with the control group.

[Study of the factors contributing to poor quality of life in chronic heart failure with reduced ejection fraction]

BACKGROUND

The increasing prevalence and poor prognosis associated with chronic heart failure (CHF) have made the improvement of quality of life (QoL) one of the main goals in the treatment of CHF patients. Since little is known about the QoL in Tunisian patients with heart failure (HF), the current study was performed to assess QoL in a sample of Tunisian patients hospitalized with HF and to identify factors related to QoL.

METHODS

In this prospective study, we evaluated patients with CHF attending the cardiology department of Habib Thameur University Hospital in a four-month period. Echocardiography was performed and patients with left ventricular ejection fraction of 45% or less were selected. QoL assessment was performed with a disease-specific instrument: the Minnesota Living with Heart Failure Questionnaire (MLHFQ) in a sample of 100 selected patients. Relationships between health-related QoL and the studied variables were examined with bivariate correlations and binary logistic regression analysis.

RESULTS

In the total sample (n = 100), mean age was 62.7 years. The majority were male (77%), married (76%), with a mean of 2.5 comorbidities, and in a New York Heart Association (NYHA) functional class III to IV (61%). Mean LVEF was 36%. Half of the patients had poor QoL on the total MLHFQ scale (median = 41.5) as well as on its physical (median = 17.5) and emotional (median = 11.25) domains. In univariate analysis, the following variables were related to poor QoL with p < 0.005: not being employed, suffering from hypertension, renal failure, anemia, being under a low-salt diet, having no regular physical activity, having the physical symptoms of HF, higher NYHA class and longer QRS duration. In multiple regression analysis, the main independent predictors of poor QoL on the total scale were higher NYHA functional class and renal dysfunction,. The data provided no evidence of an association between LVEF and QoL.

CONCLUSION

This study has found that higher NHYA functional class and chronic kidney disease are risk factors for impaired QoL, independently of disease severity among patients with heart failure.

Nutritional interventions for heart failure patients who are malnourished or at risk of malnutrition or cachexia: a systematic review and meta-analysis

Malnutrition is common in heart failure (HF), and it is associated with higher hospital readmission and mortality rates. This review aims to answer the question whether nutritional interventions aiming to increase protein and energy intake are effective at improving outcomes for patients with HF who are malnourished or at risk of malnutrition or cachexia. Systematic searches of four databases (Medline, Embase, CINAHL and Cochrane Central Register of Controlled Trials (CENTRAL)) were conducted on 21 June 2019. Randomized controlled trials (RCTs) or other interventional studies using protein or energy supplementation for adult HF patients who are malnourished or at risk of malnutrition or cachexia were included. Two independent reviewers assessed study eligibility and risk of bias. Five studies (four RCTs and one pilot RCT) met the inclusion criteria. The majority of studies were small and of limited quality. The pooled weighted mean difference (WMD) for body weight showed a benefit from the nutritional intervention by 3.83 kg (95% confidence interval (CI) 0.17 to 7.50, P = 0.04) from three trials with no significant benefit for triceps skinfold thickness (WMD = - 2.14 mm, 95% CI - 9.07 to 4.79, P = 0.55) from two trials. The combination of personalized nutrition intervention with conventional treatment led to a decrease in all-cause mortality and hospital readmission in one study. Findings of this review suggest that nutritional interventions could potentially improve outcomes in HF patients who are malnourished or at risk of malnutrition. However, the strength of the evidence is poor, and more robust studies with a larger number of participants are needed.

Feasibility and effectiveness of a multidimensional post-discharge disease management programme for heart failure patients in clinical practice: the HerzMobil Tirol programme

AIMS

It remains unclear whether transitional care management outside of a clinical trial setting provides benefits for patients with acute heart failure (AHF) after hospitalization. We evaluated the feasibility and effectiveness of a multidimensional post-discharge disease management programme using a telemedical monitoring system incorporated in a comprehensive network of heart failure nurses, resident physicians, and secondary and tertiary referral centres (HerzMobil Tirol, HMT), METHODS AND RESULTS: The non-randomized study included 508 AHF patients that were managed in HMT (n = 251) or contemporaneously in usual care (UC, n = 257) after discharge from hospital from 2016 to 2019. Groups were retrospectively matched for age and sex. The primary endpoint was time to HF readmission and all-cause mortality within 6 months. Multivariable Cox proportional hazard models were used to assess the effectiveness. The primary endpoint occurred in 48 patients (19.1%) in HMT and 89 (34.6%) in UC. Compared with UC, management by HMT was associated with a 46%-reduction in the primary endpoint (adjusted HR 0.54; 95% CI 0.37-0.77; P < 0.001). Subgroup analyses revealed consistent effectiveness. The composite of recurrent HF hospitalization and death within 6 months per 100 patient-years was 64.2 in HMT and 108.2 in UC (adjusted HR 0.41; 95% CI 0.29-0.55; P < 0.001 with death considered as a competing risk). After 1 year, 25 (10%) patients died in HMT compared with 66 (25.7%) in UC (HR 0.38; 95% CI 0.23-0.61, P < 0.001).

CONCLUSIONS

A multidimensional post-discharge disease management programme, comprising a telemedical monitoring system incorporated in a comprehensive network of specialized heart failure nurses and resident physicians, is feasible and effective in clinical practice.

Association Between Attending Physicians' Rates of Referral to Palliative Care and Location of Death in Hospitalized Adults With Serious Illness: A Population-based Cohort Study

BACKGROUND

Patients who receive palliative care are less likely to die in hospital.

OBJECTIVE

To measure the association between physician rates of referral to palliative care and location of death in hospitalized adults with serious illness.

RESEARCH DESIGN

Population-based decedent cohort study using linked health administrative data in Ontario, Canada.

SUBJECTS

A total of 7866 physicians paired with 130,862 hospitalized adults in their last year of life who died of serious illness between 2010 and 2016.

EXPOSURE

Physician annual rate of referral to palliative care (high, average, low).

MEASURES

Odds of death in hospital versus home, adjusted for patient characteristics.

RESULTS

There was nearly 4-fold variation in the proportion of patients receiving palliative care during follow-up based on attending physician referral rates: high 42.4% (n=24,433), average 24.7% (n=10,772), low 10.7% (n=6721). Referral to palliative care was also associated with being referred by palliative care specialists and in urban teaching hospitals. The proportion of patients who died in hospital according to physician referral rate were 47.7% (high), 50.1% (average), and 52.8% (low). Hospitalized patients cared for by a physician who referred to palliative care at a high rate had lower risk of dying in hospital than at home compared with patients who were referred by a physician with an average rate of referral [adjusted odds ratio 0.91; 95% confidence interval, 0.86-0.95; number needed to treat=57 (interquartile range 41-92)] and by a physician with a low rate of referral [adjusted odds ratio 0.81; 95% confidence interval, 0.77-0.84; number needed to treat =28 patients (interquartile range 23-44)].

CONCLUSIONS AND RELEVANCE

An attending physicians' rates of referral to palliative care is associated with a lower risk of dying in hospital. Therefore, patients who are cared for by physicians with higher rates of referral to palliative care are less likely to die in hospital and more likely to die at home. Standardizing referral to palliative care may help reduce physician-level variation as a barrier to access.

An update on levosimendan in acute cardiac care: applications and recommendations for optimal efficacy and safety

Introduction: In the 20 years since its introduction to the palette of intravenous hemodynamic therapies, the inodilator levosimendan has established itself as a valuable asset for the management of acute decompensated heart failure. Its pharmacology is notable for delivering inotropy via calcium sensitization without an increase in myocardial oxygen consumption.Areas covered: Experience with levosimendan has led to its applications expanding into perioperative hemodynamic support and various critical care settings, as well as an array of situations associated with acutely decompensated heart failure, such as right ventricular failure, cardiogenic shock with multi-organ dysfunction, and cardio-renal syndrome. Evidence suggests that levosimendan may be preferable to milrinone for patients in cardiogenic shock after cardiac surgery or for weaning from extracorporeal life support and may be superior to dobutamine in terms of short-term survival, especially in patients on beta-blockers. Positive effects on kidney function have been noted, further differentiating levosimendan from catecholamines and phosphodiesterase inhibitors.Expert opinion:Levosimendan can be a valuable resource in the treatment of acute cardiac dysfunction, especially in the presence of beta-blockers or ischemic cardiomyopathy. When attention is given to avoiding or correcting hypovolemia and hypokalemia, an early use of the drug in the treatment algorithm is preferred.

The Utility of CardioMEMS, a Wireless Hemodynamic Monitoring System in Reducing Heart Failure Related Hospital Readmissions

The purpose of this article is to inform nurse practitioners and other healthcare professionals regarding the utilization of CardioMEMs, a wireless pulmonary artery pressure monitoring device, in reducing heart failure-related hospital readmission rates. This article will briefly explain how CardioMEMs also helps to reduce the risk of Covid-19 in patients with heart failure.

Practice patterns in the management of congestive heart failure and post-discharge quality of life: A hospital-based cross-sectional study

Objective:

The objective of the study is to identify the etiology, risk factors, frequency of major and minor components of the Framingham criteria for heart failure, discharge medications, mortality, and quality of life after discharge from the hospital, for patients who were admitted to the in-patient unit of a tertiary care hospital in central India, with a diagnosis of congestive heart failure (CHF).

Methods:

This hospital-based cross-sectional study involved retrospective chart review of patients who were admitted to the in-patient unit with a diagnosis of CHF. These patients were then attempted to reach via their telephone numbers listed in the medical records and their current quality of life was assessed using Euro-QoL 5D questionnaire.

Results:

In the 69 patients who were admitted to the hospital with congestive cardiac failure during the pre-defined period, ischemic heart disease was the most common etiology and smoking was the most common risk factor for the development of CHF. The most common findings based on Framingham criteria were dyspnea on mild exertion, rales and bilateral ankle edema. It was determined that one-fourth of the individuals were non-compliant to the medical treatment and more than half of the patients had a poor health score.

Conclusion:

Smoking remains to be a major risk factor for patients to develop ischemic heart disease and subsequent CHF. Patients with congestive cardiac failure also had severe deterioration in their quality of life after discharge from the hospital, implying the need for improving efforts toward prevention and better management.

Effect of Inotropes on Patient-Reported Health Status in End-Stage Heart Failure: A Review of Published Clinical Trials

BACKGROUND

A growing population of patients with end-stage heart failure (HF) with reduced ejection fraction has limited treatment options to improve their quality and quantity of life. Although positive inotropes have failed to show survival benefit, these agents may enhance patient-reported health status, that is, symptoms, functional status, and health-related quality of life. We sought to review the available clinical trial data on positive inotrope use in patients with end-stage HF and to summarize evidence supporting the use of these agents to improve health status of patients with end-stage HF.

METHODS

A literature review of randomized controlled trials examining the use of positive inotropy in HF with reduced ejection fraction was conducted. We searched MEDLINE, SCOPUS, and Web of Science between January 1980 to December 2018 for randomized controlled trials that used as their main outcome measures the effects of inotrope therapy on (1) morbidity/mortality, (2) symptoms, (3) functional status, or (4) health-related quality of life. Inotropes of interest included adrenergic agents, phosphodiesterase inhibitors, calcium sensitizers, myosin activators, and SERCA2a (sarcoplasmic reticulum Ca²⁺-ATPase) modulators.

RESULTS

Twenty-two out of 26 inotrope randomized controlled trials measured the effect of inotropes on at least one patient-reported health status domain. Among the 22 studies with patient-related health status outcomes, 11 (50%) gauged symptom response, 15 (68%) reported functional capacity changes, and 12 (54%) reported health-related quality of life measures. Fourteen (64%) of these trials noted positive outcomes in at least one health status domain measured; 11 (79%) of these positive studies used agents that worked through phosphodiesterase inhibition.

CONCLUSIONS

There has been a lack of standardization surrounding measurement of patient-centered outcomes in studies of inotropes for end-stage HF with reduced ejection fraction. The degree to which positive inotropes can improve patient-reported health status and the adverse risk they pose remains unknown.

Health-Related Quality of Life and Associated Factors Among Adult Patients with Heart Failure in Wolaita Zone Governmental Hospitals, Southern Ethiopia

Background

Knowing how heart failure affects patients’ quality of life and its associated factors are crucial for a better patient-centred approach and management. Therefore, this study aims to assess health-related quality of life and its associated factors among adult heart failure patients in southern Ethiopia hospitals.

Methods

The facility-based cross-sectional study design was conducted in Wolaita zone governmental hospitals from March to April 2018. The population was all adult heart failure patients in the chronic illness follow-up clinic and inpatient department. All adult heart failure patients on follow-up clinic and inpatient departments who have at least a 6-month follow-up were included in the study. In contrast, patients who had chronic comorbidities were excluded from the study. Minnesota Living with Heart Failure Questionnaire (MLHFQ) tool was used to measure the outcome variable health-related quality of life (HRQoL). Interviews and client medical record reviews also collected socio-demographic, clinical and behavioural characteristics of participants. The data were analyzed using STATA version 14, and multiple linear regression analysis with P-value < 0.05 was used to measure the degree of association between HRQoL and independent variables.

Results

A total of 372 patients participated in the study. The HRQoL score for the physical, emotional, and total were 22.2, 7.7, and 46.37, respectively. HRQoL was significantly associated with gender, age, family size, occupation, residency, and recent admission within the past six months, New York Heart Association (NYHA) functional class, department of treatment, salt intake, and health perception.

Conclusion

Generally, the HRQoL for patients with heart failure was found to be low. Besides the variables age and gender of participants, family size, occupation, residency, admission history, salt intake, and NYHA class were significant factors for the HRQoL of patients with heart failure.

Feasibility of using a novel automatic cardiac segmentation algorithm in the clinical routine of lung cancer patients

Incidental radiation exposure to the heart during lung cancer radiotherapy is associated with radiation-induced heart disease and increased rates of mortality. By considering the respiratory-induced motion of the heart it is possible to create a radiotherapy plan that results in a lower overall cardiac dose. This approach is challenging using current clinical practices: manual contouring of the heart is time consuming, and subject to inter- and intra-observer variability. In this work, we investigate the feasibility of our previously developed, atlas-based, automatic heart segmentation tool to delineate the heart in four-dimensional x-ray computed tomography (4D-CT) images. We used a dataset comprising 19 patients receiving radiotherapy for lung cancer, with 4D-CT imaging acquired at 10 respiratory phases and with a maximum intensity projection image generated from these. For each patient, one of four experienced radiation oncologists contoured the heart on each respiratory phase image and the maximum intensity image. Automatic segmentation of the heart on these same patient image sets was achieved using a leave-one-out approach, where for each patient the remaining 18 were used as an atlas set. The consistency of the automatic segmentation relative to manual contouring was evaluated using the Dice similarity coefficient (DSC) and mean absolute surface-to-surface distance (MASD). The DSC and MASD are comparable to inter-observer variability in clinically acceptable whole heart delineations (average DSC > 0.93 and average MASD < 2.0 mm in all the respiratory phases). The comparison between automatic and manual delineations on the maximum intensity images produced an overall mean DSC of 0.929 and a mean MASD of 2.07 mm. The automatic, atlas-based segmentation tool produces clinically consistent and robust heart delineations and is easy to implement in the routine care of lung cancer patients.

Heart failure in the last year: progress and perspective

Research about heart failure (HF) has made major progress in the last years. We give here an update on the most recent findings. Landmark trials have established new treatments for HF with reduced ejection fraction. Sacubitril/valsartan was superior to enalapril in PARADIGM‐HF trial, and its initiation during hospitalization for acute HF or early after discharge can now be considered. More recently, new therapeutic pathways have been developed. In the DAPA‐HF and EMPEROR‐Reduced trials, dapagliflozin and empagliflozin reduced the risk of the primary composite endpoint, compared with placebo [hazard ratio (HR) 0.74; 95% confidence interval (CI) 0.65–0.85; P < 0.001 and HR 0.75; 95% CI 0.65–0.86; P < 0.001, respectively]. Second, vericiguat, an oral soluble guanylate cyclase stimulator, reduced the composite endpoint of cardiovascular death or HF hospitalization vs. placebo (HR 0.90; 95% CI 0.82–0.98; P = 0.02). On the other hand, both the diagnosis and treatment of HF with preserved ejection fraction, as well as management of advanced HF and acute HF, remain challenging. A better phenotyping of patients with HF would be helpful for prognostic stratification and treatment selection. Further aspects, such as the use of devices, treatment of arrhythmias, and percutaneous treatment of valvular heart disease in patients with HF, are also discussed and reviewed in this article.

Cardiorespiratory strain during stroke rehabilitation: Are patients trained enough? A systematic review

BACKGROUND

Rehabilitation is a mandatory component of stroke management, aiming to recover functional capacity and independence. To that end, physical therapy sessions must involve adequate intensity in terms of cardiopulmonary stress to meet the physiological demands of independent living.

OBJECTIVE

The aim of this systematic review was to determine the current level of cardiopulmonary strain during rehabilitation sessions in stroke patients.

METHODS

Three electronic databases (PubMed, CINAHL and Embase. com) were searched to identify observational studies that documented cardiopulmonary strain during rehabilitation sessions in post-stroke patients (last search performed in February 2019). A manual cross-referencing search was also performed. To be included, articles needed to report data related to both cardiopulmonary strain (heart rate, oxygen consumption or energy expenditure) and active therapy time. The methodological quality of each study was assessed with the Evidence-Based Librarianship Critical Appraisal Tool. Data related to both cardiorespiratory strain and active therapy time were extracted from selected articles.

RESULTS

Four of 43 full-text articles assessed for eligibility met the inclusion criteria. Results extracted from these articles suggested that the intensity of rehabilitation sessions was insufficient to induce a cardiopulmonary training effect in a post-stroke context as measured by metabolic stress. Patients were inactive from 21% to 80% of the therapy time. The Evidence-Based Librarianship tool scores ranged from 65% (15/23) to 91% (21/23), which indicates questionable to good quality.

CONCLUSION

The current literature on cardiopulmonary solicitation during stroke rehabilitation sessions is poor in terms of both the number of studies available and their methodological quality. Summarized results tend to support previous claims that rehabilitation sessions offered to stroke patients are of suboptimal cardiopulmonary strain, which can interfere with their capacity to regain functional independence.

Association of Receipt of Palliative Care Interventions With Health Care Use, Quality of Life, and Symptom Burden Among Adults With Chronic Noncancer Illness: A Systematic Review and Meta-analysis

IMPORTANCE

The evidence for palliative care exists predominantly for patients with cancer. The effect of palliative care on important end-of-life outcomes in patients with noncancer illness is unclear.

OBJECTIVE

To measure the association between palliative care and acute health care use, quality of life (QOL), and symptom burden in adults with chronic noncancer illnesses.

DATA SOURCES

MEDLINE, Embase, CINAHL, PsycINFO, and PubMed from inception to April 18, 2020.

STUDY SELECTION

Randomized clinical trials of palliative care interventions in adults with chronic noncancer illness. Studies involving at least 50% of patients with cancer were excluded.

DATA EXTRACTION AND SYNTHESIS

Two reviewers independently screened, selected, and extracted data from studies. Narrative synthesis was conducted for all trials. All outcomes were analyzed using random-effects meta-analysis.

MAIN OUTCOMES AND MEASURES

Acute health care use (hospitalizations and emergency department use), disease-generic and disease-specific quality of life (QOL), and symptoms, with estimates of QOL translated to units of the Functional Assessment of Chronic Illness Therapy-Palliative Care scale (range, 0 [worst] to 184 [best]; minimal clinically important difference, 9 points) and symptoms translated to units of the Edmonton Symptom Assessment Scale global distress score (range, 0 [best] to 90 [worst]; minimal clinically important difference, 5.7 points).

RESULTS

Twenty-eight trials provided data on 13 664 patients (mean age, 74 years; 46% were women). Ten trials were of heart failure (n = 4068 patients), 11 of mixed disease (n = 8119), 4 of dementia (n = 1036), and 3 of chronic obstructive pulmonary disease (n = 441). Palliative care, compared with usual care, was statistically significantly associated with less emergency department use (9 trials [n = 2712]; 20% vs 24%; odds ratio, 0.82 [95% CI, 0.68-1.00]; I2 = 3%), less hospitalization (14 trials [n = 3706]; 38% vs 42%; odds ratio, 0.80 [95% CI, 0.65-0.99]; I2 = 41%), and modestly lower symptom burden (11 trials [n = 2598]; pooled standardized mean difference (SMD), -0.12; [95% CI, -0.20 to -0.03]; I2 = 0%; Edmonton Symptom Assessment Scale score mean difference, -1.6 [95% CI, -2.6 to -0.4]). Palliative care was not significantly associated with disease-generic QOL (6 trials [n = 1334]; SMD, 0.18 [95% CI, -0.24 to 0.61]; I2 = 87%; Functional Assessment of Chronic Illness Therapy-Palliative Care score mean difference, 4.7 [95% CI, -6.3 to 15.9]) or disease-specific measures of QOL (11 trials [n = 2204]; SMD, 0.07 [95% CI, -0.09 to 0.23]; I2 = 68%).

CONCLUSIONS AND RELEVANCE

In this systematic review and meta-analysis of randomized clinical trials of patients with primarily noncancer illness, palliative care, compared with usual care, was statistically significantly associated with less acute health care use and modestly lower symptom burden, but there was no significant difference in quality of life. Analyses for some outcomes were based predominantly on studies of patients with heart failure, which may limit generalizability to other chronic illnesses.

Optimal Usage of Sacubitril/Valsartan for the Treatment of Heart Failure: The Importance of Optimizing Heart Failure Care in Canada

BACKGROUND

Heart failure (HF) with reduced ejection fraction represents approximately 50% of the 600,000 Canadians currently living with HF and over 90,000 new cases diagnosed each year. The angiotensin receptor neprilysin inhibitor, sacubitril/valsartan, demonstrated superior efficacy in reducing cardiovascular death and HF hospitalization over standard of care therapy.

METHODS

The potential magnitude of benefit in Canada with respect to preventing or postponing deaths and reducing hospitalizations resulting from its optimal implementation in patients with HF with an ejection fraction <40% was estimated based on published sources.

RESULTS

Of the potentially eligible 225,562 patients, this would amount to the prevention of 4699 cardiovascular deaths and first HF hospitalizations, 3698 thirty-day HF readmissions, and 2820 deaths due to all-cause mortality. The number of patients receiving sacubitril/valsartan nationally in 2018 was 27,267. This represents approximately 12% of the calculated eligible population for this therapy in Canada.

CONCLUSIONS

The findings from this analysis suggest that a substantial number of deaths, hospitalizations, and HF readmissions could potentially be avoided by optimal usage of sacubitril/valsartan therapy in Canada. This emphasizes the importance of rapidly and appropriately implementing evidence-based medications into routine clinical practice, to achieve the best possible outcomes for our patients with HF and to reduce the high burden and cost of HF in Canada.