The global epidemiology of heart failure

Predicting potential biomarkers and immune infiltration characteristics in heart failure

BACKGROUND

Studies have demonstrated that immune cell activation and their infiltration in the myocardium can have adverse effects on the heart, contributing to the pathogenesis of heart failure (HF). The purpose of this study is used by bioinformatics analysis to determine the potential diagnostic markers of heart failure and establish an applicable model to predict the association between heart failure and immune cell infiltration.

METHODS

Firstly, gene expression profiles of dilated heart disease GSE3585 and GSE120895 were obtained in Gene Expression Omnibus (GEO) database. This study then selected differentially expressed genes (DEGs) in 54 patients with HF and 13 healthy controls. In this study, biomarkers were identified using Least Absolute Shrinkage and Selector Operation (LASSO) and Support Vector Machine-Recursive Feature Elimination (SVM-RFE). Additionally, we evaluated the prognostic discrimination performance by the receiver operating characteristic (ROC) curve. Cell type Identification by Estimating Relative Subsets of RNA Transcripts (CIBERSORT) was used for analyzing immune cell infiltration in HF tissues. Lastly, immune biomarkers were correlated with each other.

RESULT

After 24 DEGs were analyzed using a combinatorial model of LASSO regression and SVM-RFE analysis, four key genes were obtained, namely NSG1, NPPB, PHLDA1, and SERPINE2.The area under the curve (AUC) of these four genes were greater than 0.8. Subsequently, using CIBERPORT, we also found that compared with normal people, the proportion of M1 macrophages and activated mast cells in heart failure tissues decreased. In addition, correlation analysis showed that NPPB, PHLDA1 and SERPINE2 were associated with immune cell infiltration.

CONCLUSION

NSG1, NPPB, PHLDA1 and SERPINE2 were identified as potential biomarkers of heart failure. It reveals the comprehensive role of relevant central genes in immune infiltration, which provides a new research idea for the treatment and early detection in heart failure.

Dietary Vitamin C Deficiency Is Associated With Health-Related Quality of Life and Cardiac Event-free Survival in Adults With Heart Failure

BACKGROUND

Vitamin C deficiency is prevalent in adults with heart failure (HF). Little is known about the relationship of dietary vitamin C deficiency with health outcomes in adults with HF.

OBJECTIVE

The study's aim was to determine the relationships of vitamin C deficiency measured at baseline with health-related quality of life (HRQOL) and cardiac event-free survival in patients with HF measured 1 year later.

METHOD

A total of 251 patients with HF completed a 4-day food diary. Dietary vitamin C deficiency was defined as daily intake less than the estimated average requirement from the Institute of Medicine of 75 mg/d for men and 60 mg/d for women. Health-related quality of life was assessed using the Minnesota Living with Heart Failure Questionnaire at 12 months. Patients were followed for a median of 1 year to determine time to the first event of cardiac-related hospitalization or death. Data were analyzed by hierarchical linear and Cox proportional hazards regressions.

RESULTS

One hundred patients (40%) had vitamin C deficiency. Dietary vitamin C deficiency was associated with poorer HRQOL at 12 months (β = 0.16, P = .02) after controlling for demographic and clinical variables. During the follow-up period, 59 patients (24%) had cardiac events. In Cox regression, vitamin C deficiency predicted shorter cardiac event-free survival after adjusting for the same covariates (hazards ratio, 1.95; 95% confidence interval, 1.08-3.51).

CONCLUSION

Vitamin C deficiency was associated with poorer HRQOL and shorter cardiac event-free survival in patients with HF. The findings suggest that encouraging patients with HF to consume a diet rich in fruits/vegetables to prevent vitamin C deficiency may lead to better health outcomes.

Heart failure in chronic kidney disease: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference

The incidence and prevalence of heart failure (HF) and chronic kidney disease (CKD) are increasing, and as such a better understanding of the interface between both conditions is imperative for developing optimal strategies for their detection, prevention, diagnosis, and management. To this end, Kidney Disease: Improving Global Outcomes (KDIGO) convened an international, multidisciplinary Controversies Conference titled Heart Failure in CKD. Breakout group discussions included (i) HF with preserved ejection fraction (HFpEF) and nondialysis CKD, (ii) HF with reduced ejection fraction (HFrEF) and nondialysis CKD, (iii) HFpEF and dialysis-dependent CKD, (iv) HFrEF and dialysis-dependent CKD, and (v) HF in kidney transplant patients. The questions that formed the basis of discussions are available on the KDIGO website http://kdigo.org/conferences/heart-failure-in-ckd/, and the deliberations from the conference are summarized here.

Can home care for homebound patients with chronic heart failure reduce hospitalizations and costs?

Background

Congestive heart failure (CHF), a common problem in adults, is associated with multiple hospitalizations, high mortality rates and high costs.

Purpose

To evaluate whether home care for homebound patients with CHF reduces healthcare service utilization and overall costs.

Methods

A retrospective study of healthcare utilization among homebound patients who received home care for CHF from 2012–1015. The outcome measures were number of hospital admissions per month, total number of hospitalization days and days for CHF only, emergency room visits, and overall costs. A comparison was conducted between the 6-month period prior to entry into home care and the time in home care.

Results

Over the study period 196 patients were treated by home care for CHF with a mean age of 79.4±9.5 years. 113 (57.7%) were women. Compared to the six months prior to home care, there were statistically significant decreases in hospitalizations (46.3%), in the number of total in-hospital days (28.7%), in the number of in-hospital days for CHF (66.7%), in emergency room visits (47%), and in overall costs (23.9%).

Conclusion

Home care for homebound adults with CHF can reduce healthcare utilization and healthcare costs.

Effects of Vitamin D supplementation on physical activity of patients with Heart Failure

OBJECTIVE

To see the role of Vitamin D supplementation on physical status of patients suffering from Congestive Heart Failure (dilated cardiomyopathy).

METHODS

In this nonrandomized clinical trial, Forty three Patients with dilated cardiomyopathy who were not showing any significant improvements in physical performance on optimal treatment of heart failure were included. Vitamin D (200,000 IU) supplementation on weekly basis for a period of 12 weeks was added to heart failure treatment. And its effect was seen on 6 minutes' walk distance and Pro-BNP levels. SPSS version 19 was used for data analysis. Dependent sample t-test was used to see the significant effect of vitamin D supplementation on pre- intervention vitamin D levels, 6MWD and Pro-BNP. Taking p-value <0.05 as significant.

RESULTS

On clinical assessment most of the patients were in NYHA class II (65%), the percentages of NYHA Class I, III and IV was 19%, 9% and 7% respectively. The baseline mean vitamin D level of the study group was 16.59±3.54ng/ml and it raised to 31.97±3.64ng/ml after 12 weeks of supplementation with vitamin D, p value<0.0005. The mean distance travelled by the study group before the intervention was 806±380ft while it increased to 945±393ft after the intervention, p value of 0.008. The mean of pro-BNP level of the study group before the intervention was 1024±635 while it improved to 159±80 after the intervention with a significant p value<0.0005.

CONCLUSION

Vitamin D supplementation decreases the severity of HF as reflected by reduction in serum pro-BNP levels and significant increase in six minutes' walk distance.

Heart failure in low- and middle-income countries: background, rationale, and design of the INTERnational Congestive Heart Failure Study (INTER-CHF)

BACKGROUND

Although heart failure (HF) has been referred to as a global epidemic, most HF information comes from high-income countries, with little information about low-income countries (LIC) and middle-income countries (MIC) in Africa, Asia, the Middle East, and South America, which make up the majority of the world's population.

METHODS

The INTERnational Congestive Heart Failure Study is a cohort study of 5,813 HF patients enrolled in 108 centers in 16 LIC and MIC. At baseline, data were recorded on sociodemographic and clinical risk factors, HF etiology, laboratory variables, management, and barriers to evidence-based HF care at the patient, physician, and system levels. We sought to enroll consecutive and consenting patients ≥18 years of age with a clinical diagnosis of HF seen in outpatient clinics (2/3 of patients) or inpatient hospital wards (1/3 of patients). Patients were followed up at 6 and 12 months post-enrollment to record clinical status, treatments, and clinical outcomes such as death and hospitalizations. In the 5,813 enrolled HF patients, the mean age was 59 ± 15 years, 40% were female, 62% had a history of hypertension, 30% had diabetes, 21% had prior myocardial infarction, 64% were recruited from outpatient clinics, 36% lived in rural areas, and 29% had HF with preserved left ventricular ejection fraction.

CONCLUSIONS

This unique HF registry aims to systematically gather information on sociodemographic and clinical risk factors, etiologies, treatments, barriers to evidence-based care, and outcomes of HF in LIC and MIC. This information will help improve the management of HF globally.

Determining the cost of obesity and its common comorbidities from a commercial claims database

What is already known about this subject Obesity is highly prevalent and costly in the US. Obesity often leads to other comorbid conditions, including diabetes and hypertension. Obesity prevention efforts can reduce healthcare costs. What this study adds Obesity combined with other comorbidities significantly increases healthcare costs per patient visit. The combination of obesity and depression exacerbates costs. The most expensive series of chronic conditions in this study included obesity, diabetes, hypertension and depression. Our objectives were to determine payments made by commercial healthcare providers in the US for adults diagnosed with obesity, and those comorbid with any combination of selected chronic conditions. Using a commercial claims and encounters database (n = 3,562,717), we evaluated an adult study population that had at least one in-patient visit, outpatient visit or emergency department visit, and received a primary or secondary diagnosis of obesity. Persons were categorized by one or more comorbid diagnoses for diabetes mellitus, hypertension, depression or congestive heart failure. We adjusted for age and gender, and calculated the mean total net expenditures (in 2012, $US) for each combination of comorbid conditions based on individual visits to an in-patient, outpatient or emergency department setting. Among 50,717 claims with diagnosis of obesity, the mean net expenditure for in-patient and outpatient services was $ 1907 per patient per visit. Persons diagnosed with obesity and other comorbidities observed an increase in total net expenditures. Obesity and congestive heart failure observed the highest increase among single comorbidities at $ 5275. For persons with obesity and two other comorbidities, diabetes mellitus and depression was the highest at $ 15,226. The most expensive condition was obesity, diabetes mellitus, hypertension and depression at $ 15,733. Compared with average medical claims, persons diagnosed with obesity and other common chronic conditions experience significant increases in medical costs. These costs are often driven higher by time spent as in-patients. By controlling and reducing the prevalence of obesity, we may see significant decreases in medical expenditures.

Low literacy is associated with increased risk of hospitalization and death among individuals with heart failure

BACKGROUND

Low literacy increases the risk for many adverse health outcomes, but the relationship between literacy and adverse outcomes in heart failure (HF) has not been well studied.

METHODS

We studied a cohort of ambulatory patients with symptomatic HF (NYHA Class II-IV within the past 6 months) who were enrolled in a randomized controlled trial of self-care training recruited from internal medicine and cardiology clinics at four academic medical centers in the US. The primary outcome was combined all-cause hospitalization or death, with a secondary outcome of hospitalization for HF. Outcomes were assessed through blinded interviews and subsequent chart reviews, with adjudication of cause by a panel of masked assessors. Literacy was measured using the short Test of Functional Health Literacy in Adults. We used negative binomial regression to examine whether the incidence of the primary and secondary outcomes differed according to literacy.

RESULTS

Of the 595 study participants, 37 % had low literacy. Mean age was 61, 31 % were NYHA class III/IV at baseline, 16 % were Latino, and 38 % were African-American. Those with low literacy were older, had a higher NYHA class, and were more likely to be Latino (all p < 0.001). Adjusting for site only, participants with low literacy had an incidence rate ratio (IRR) of 1.39 (95 % CI: 0.99, 1.94) for all-cause hospitalization or death and 1.36 (1.11, 1.66) for HF-related hospitalization. After adjusting for demographic, clinical, and self-management factors, the IRRs were 1.31 (1.06, 1.63) for all-cause hospitalization and death and 1.46 (1.20, 1.78) for HF-related hospitalization.

CONCLUSIONS

Low literacy increased the risk of hospitalization for ambulatory patients with heart failure. Interventions designed to mitigate literacy-related disparities in outcomes are warranted.

Can vitamin D supplementation improve the severity of congestive heart failure?

The aim of the present study was to investigate whether vitamin D supplementation could improve biochemical findings and functional capacity of patients with heart failure (HF). One hundred patients with New York Heart Association (NYHA) class I through III HF were included in this prospective study and their 25-hydroxyvitamin D levels were evaluated. Only 6% of the participants had a sufficient serum concentration of 25(OH) D >30 nmol/L. Patients with insufficient or deficient serum levels of 25(OH) D (<30 ng/mL and <20 ng/mL, respectively) received oral vitamin D3 (cholecalciferol) for a total period of 4 months. Vitamin D supplementation increased mean serum concentration of 25(OH) D from 12.63±7.60 nmol/L to 54.49±18.01 nmol/L (P<.001). After vitamin D supplementation, the serum level of pro-brain natriuretic peptide markedly decreased (P<.001). Cholecalciferol significantly decreased high-sensitivity C-reactive protein level (P<.001). Restoration of serum 25(OH) D level was also associated with substantial improvement in NYHA class (P<.001) and 6-minute walk distance (P<.001).

Racial and ethnic differences in incident hospitalized heart failure in postmenopausal women: the Women's Health Initiative

BACKGROUND

The differences in the incidence of heart failure by race/ethnicity and the potential mechanisms for these differences are largely unexplored in women.

METHODS AND RESULTS

A total of 156 143 postmenopausal women free of self-reported heart failure enrolled from 1993 to 1998 at 40 clinical centers throughout the United States as part of the Women's Health Initiative and were followed up until 2005, for an average of 7.8 years, for incident hospitalized heart failure. Incident rates, hazard ratios (HRs), and 95% confidence intervals were determined by use of the Cox proportional hazard model comparing racial/ethnic groups, and population-attributable risk percentages were calculated for each racial/ethnic group. Blacks had the highest age-adjusted incidence of heart failure (380 in 100 000 person-years), followed by whites (274), Hispanics (193), and Asian/Pacific Islanders (103). The excess risk in blacks compared with whites (age-adjusted HR=1.45) was significantly attenuated by adjustment for household income (HR=0.97) and diabetes mellitus (HR=0.89), but the lower risk in Hispanics (age-adjusted HR=0.72) and Asian/Pacific Islanders (age-adjusted HR=0.44) remained despite adjustment for traditional risk factors, socioeconomic status, lifestyle, and access-to-care variables. The effect of adjustment for interim coronary heart disease on nonwhite versus white HRs for heart failure differed by race/ethnic group.

CONCLUSIONS

Asian/Pacific Islander and Hispanic women have a lower incidence of heart failure and black women have higher rates of heart failure compared with white women. The excess risk of incident heart failure in black women is explained largely by adjustment for lower household incomes and diabetes mellitus in black women, whereas the lower rates of heart failure in Asian/Pacific Islanders and Hispanics are largely unexplained by the risk factors measured in this study.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Unique identifier: NCT00000611.

Referral and use of heart failure clinics: what factors are related to use?

BACKGROUND

Heart failure (HF) clinics have been shown to reduce hospital readmissions and generally have favourable effects on quality of life, survival, and care costs. This study investigated the rates of referral and use of HF clinics and examined factors related to program use.

METHODS

This study represents a secondary analysis of a larger prospective cohort study conducted in Ontario. In hospital, 474 HF inpatients from 11 hospitals across Ontario completed a survey that examined predisposing, enabling, and need factors affecting HF clinic use. Then 1 year later, 271 HF patients completed a mailed survey that assessed referral to and use of HF clinics.

RESULTS

Forty-one patients (15.2%) self-reported referral, and 35 (13%) self-reported attending an HF clinic. Generalized estimating equations showed that factors related to greater program use were having an HF clinic at the site of hospital recruitment (odds ratio [OR] = 8.40; P = 0.04), referral to other disease management programs (OR = 4.87; P = 0.04), higher education (OR = 4.61; P = 0.02), lower stress (OR = 0.93; P = 0.03), and lower functional status (OR = 0.97; P = 0.03).

CONCLUSION

Similar to previous research, only one-seventh of HF patients were referred to and used an HF clinic. Both patient-level and health-system factors were related to HF clinic use. Given the benefits of HF clinics, more research examining how equitable access can be increased is needed. Also, the appropriateness and cost repercussions of use of multiple disease management programs should be investigated.

Exploring the beliefs of heart failure patients towards their heart failure medicines and self care activities

AIM

To identify Heart Failure patients' beliefs towards their medications and how these beliefs relate to adherence.

METHOD

Patients attending a multi-disciplinary, community based heart failure clinic on the Gold Coast, Australia were interviewed using a questionnaire composed of fours parts: repertory grid technique; Beliefs About Medicines Questionnaire (BMQ); Medicines Adherence Reporting Scale (MARS); demographic details. Patients were divided into those categorised as adherent (MARS score ≥ 23) and those categorised as non-adherent (MARS score < 23). Necessity beliefs scores from BMQ and the frequency of statements generated from the repertory grid portion of the questionnaire were compared between these two groups.

RESULTS

Forty-three patients were interviewed with a mean age (±SD) of 64 (±17) years and thirty-six (83.7 %) were male. Thirty-seven (86.0 %) patients were categorised as adherent; the remaining six (14.0 %) as non-adherent. The 43 patients generated a total of 262 statements about their medicines. The three most common themes identified were Related to fluid (36.6 %), Helps the heart (31.7 %) and Related to weight (13.7 %). There was a significantly higher median necessity score in the adherent group compared to the non adherent group (22.0 vs. 19.5, p = 0.0272). Patients with a strong necessity score also had significantly higher self reported adherence compared to patients with a strong concerns score (21.5 vs. 18.0, p = 0.006).

CONCLUSION

This study suggests that patients with heart failure possessing a strong belief in the necessity of their treatment regimen are more likely to demonstrate better adherence.

Systolic Strain Abnormalities to Predict Hospital Readmission in Patients With Heart Failure and Normal Ejection Fraction

Background

Despite intensive investigation, the pathogenesis of heart failure with normal ejection fraction (HFNEF) remains unclear. We hypothesized that subtle abnormalities of systolic function might play a role, and that abnormal systolic strain and strain rate would provide a marker for adverse outcomes.

Methods

Patients of new CHF and left ventricular ejection fraction > 50% were included. Exclusion criteria were recent myocardial infarction, severe valvular heart disease, severe left ventricular hypertrophy (septum >1.8 cm), or a technically insufficient echocardiogram. Average peak systolic strain and strain rate were measured using an off-line grey scale imaging technique. Systolic strain and strain rate for readmitted patients were compared with those who remained readmission-free.

Results

One hundred consecutive patients with a 1st admission for HFNEF from January 1, 2004 through December 31, 2007, inclusive, were analyzed. Fifty two patients were readmitted with a primary diagnosis of heart failure. Systolic strain and strain rates were reduced in both study groups compared to controls. However, systolic strain did not differ significantly between the two groups (-11.7% for those readmitted compared with -12.9% for those free from readmission, P = 0.198) and systolic strain rates also were similar (-1.05 s^-1 versus -1.09 s^-1, P = 0.545). E/e’ was significantly higher in readmitted patients compared with those who remained free from readmission (14.5 versus 11.0, P = 0.013). E/e’ (OR 1.189, 95% CI 1.026-1.378; P = 0.021) was found to be an independent predictor for HFNEF readmission.

Conclusions

Among patients with new onset HFNEF, SS and SR rates are reduced compared with patients free of HFNEF, but do not predict hospital readmission. Elevated E/e’ is a predictor of readmission in these patients.

Adherence to the European Society of Cardiology (ESC) guidelines for chronic heart failure--a national survey of the cardiologists in Pakistan

BACKGROUND

The aims of this study were to evaluate the awareness of and attitudes towards the 2005 European Society of Cardiology (ESC) guidelines for Heart Failure (HF) of the cardiologists in Pakistan and assess barriers to adherence to guidelines.

METHODS

A cross-sectional survey was conducted in person from March to July 2009 to all cardiologists practicing in 4 major cities in Pakistan (Karachi, Lahore, Quetta and Peshawar). A validated, semi-structured questionnaire assessing ESC 2005 Guidelines for HF was used to obtain information from cardiologists. It included questions about awareness and relevance of HF guidelines (See Additional File 1). Respondents' management choices were compared with those of an expert panel based on the guidelines for three fictitious patient cases. Cardiologists were also asked about major barriers to adherence to guidelines.

RESULTS

A total of 372 cardiologists were approached; 305 consented to participate (overall response rate, 82.0%). The survey showed a very high awareness of CHF guidelines; 97.4% aware of any guideline. About 13.8% considered ESC guidelines as relevant or very relevant for guiding treatment decisions while 92.8% chose AHA guidelines in relevance. 87.2% of respondents perceived that they adhered to the HF guidelines. For the patient cases, the proportions of respondents who made recommendations that completely matched those of the guidelines were 7% (Scenario 1), 0% (Scenario 2) and 20% (Scenario 3). Respondents considered patient compliance (59%) and cost/health economics (50%) as major barriers to guideline implementation.

CONCLUSION

We found important self reported departures from recommended HF management guidelines among cardiologists of Pakistan.

Rurality and event-free survival in patients with heart failure

BACKGROUND

Evidence of health disparities between urban and rural populations usually favors urban dwellers. The impact of rurality on heart failure (HF) outcomes is unknown.

OBJECTIVE

We compared event-free survival between HF patients living in urban and rural areas.

METHODS

In this longitudinal study, 136 patients with HF (male, 70%; age, mean ± SD 61 ± 11 years; New York Heart Association class III/IV, 60%) were enrolled. Patients' emergency department visits for HF exacerbation and rehospitalization during follow-up were identified. Rural status was determined by rural-urban commuting area code. Survival analysis was used to determine the effect of rurality on outcomes while controlling for relevant demographic, clinical, and psychosocial variables.

RESULTS

Rural patients (64%) had longer event-free survival than urban patients (P = .015). Rurality (P = .04) predicted event-free survival after controlling for age, marital status, New York Heart Association class, medications, adherence to medications, depressive symptoms, and social support.

CONCLUSIONS

Rural patients were less likely than their urban counterparts to experience an event. Further research is needed to identify protective factors that may be unique to rural settings.

Clinical features of heart failure hospitalization in younger and elderly patients in Taiwan

BACKGROUND

  This study compared the comorbidities, drugs, expenses and in-hospital mortality between younger and elderly patients hospitalized with heart failure.

METHODS

A random sample of 1,000.000 insurants of the National Health Insurance program of Taiwan in 2005 was used. Comparisons were made between younger (20-64years) and elderly (≥65years) patients.

RESULTS

Heart failure hospitalization was identified in 2692 patients. Ageing, female sex, diabetes, hypertension, chronic obstructive pulmonary disease, nephropathy, infection and ischaemic heart disease were significantly associated with heart failure hospitalization. The incidence was 88 and 2181 per 100,000 population, in younger and elderly people, respectively. The most common comorbidity in the elderly was hypertension (38·3%), followed by infection (32·0%) and ischaemic heart disease (31·9%). In younger patients, hypertension (41·3%), diabetes (35·5%) and ischaemic heart disease (29·8%) were the most common comorbidity. Diuretics were the most common drugs for both the younger (74·4%) and the elderly (76·9%) patients, followed by angiotensin-converting enzyme inhibitors and/or angiotensin receptor blockers and aspirin. The length of stay was longer (17·1 vs. 11·0days, P<0·0001), total expense higher (105,290·5 vs. 85,473·6 New Taiwan Dollars, P<0·05) and in-hospital mortality higher (4·2% vs. 2·7%, P=0·0823) in the elderly. Length of stay, nephropathy, infection, ischaemic heart disease and peripheral arterial disease were associated with expenses. In-hospital mortality was associated with age, length of stay, cancer, infection and peripheral arterial disease.

CONCLUSIONS

The elderly have a 25-fold higher risk of heart failure hospitalization, longer length of in-hospital stay, higher total medical expense and higher in-hospital mortality.

Comparison of health-related quality of life between American and Taiwanese heart failure patients

Few investigators have compared health-related quality of life (HRQOL) in heart failure (HF) patients from different countries.The purposes of this study were to compare HRQOL between American (n = 87) and Taiwanese (n = 88) HF patients and to determine factors associated with HRQOL in both groups. In this cross-sectional survey, HRQOL was measured using the Minnesota Living with Heart Failure Questionnaire. American patients rated their HRQOL worse than Taiwanese patients did. Sociodemographics, disease severity, and symptom severity were associated with HRQOL, accounting for 42.4% of the variance in HRQOL in Americans and 57.3% in Taiwanese. Symptom severity was the most important predictor of HRQOL in both groups. Interventions targeting symptom severity could improve HF patients' HRQOL.

Should vitamin D status be assessed in patients with congestive heart failure?

For decades the vitamin D biological system has been considered almost exclusively as the master integrator of calcium-phosphate homeostasis and bone metabolism. More recently, the discovery that many human tissues and cells, which do not directly participate in mineral ion homeostasis, express the vitamin D receptor (VDR) and are able to convert the circulating pro-hormone 25-hydroxyvitamin D in its active form, 1,25-dihydroxyvitamin D, has provided new insights into the biological function of this peculiar endocrine system. Several reports have highlighted a variety of human diseases possibly related to vitamin D insufficiency or deficiency (respectively defined as 25-hydroxyvitamin D serum levels lower than 30 or lower than 20 ng/ml). In particular, experimental and observational studies, including those published in this journal issue, support the concept that vitamin D deficiency is involved in the pathogenesis of congestive heart failure, a disabling condition affecting over 15 million of patients worldwide. Considering that circulating levels of 25-hydroxyvitamin D represent the accepted clinical indicator of individual vitamin D status, the measurement of this pro-hormone can be regarded as an appropriate and cost-effective screening tool in patients with chronic heart failure.

Targeting fibrosis for the treatment of heart failure: a role for transforming growth factor-β

Chronic heart failure (CHF) is a growing health problem in developed nations. The pathological accumulation of extracellular matrix is a key contributor to CHF in both diabetic and nondiabetic states, resulting in progressive stiffening of the ventricular walls and loss of contractility. Proinflammatory disease processes, including inflammatory cytokine activation, contribute to accumulation of extracellular matrix in the heart. Transforming growth factor-β is a key profibrotic cytokine mediating fibrosis. Current therapeutic strategies do not directly target the profibrotic inflammatory processes occurring in the heart and hence there is a clear unmet clinical need to develop new therapeutic agents targeting fibrosis. Accordingly, strategies that inhibit proinflammatory cytokine activation and pathological accumulation of extracellular matrix (ECM) provide a potential therapeutic target for prevention of heart failure. This review focuses on the therapeutic targeting of TGF-β in the prevention of pathological fibrosis in the heart.

Effects of combined aging and heart failure on visceral sympathetic nerve and cardiovascular responses to progressive hyperthermia in F344 rats

Sympathetic nerve discharge (SND) responses to hyperthermia are attenuated in aged rats without heart failure (HF) and in young HF (Y(HF)) rats, demonstrating that individually aging and HF alter SND regulation. However, the combined effects of aging and HF on SND regulation to heat stress are unknown, despite the high prevalence of HF in aged individuals. We hypothesized that SND responses to heating would be additive when aging and HF are combined, demonstrated by marked reductions in SND and mean arterial pressure (MAP) responses to heating in aged HF (A(HF)) compared with aged sham HF (A(SHAM)) rats, and in A(HF) compared with Y(HF) rats. Renal and splenic SND responses to hyperthermia (colonic temperature increased to 41.5°C) were determined in anesthetized Y(HF), young sham (Y(SHAM)), A(HF), and A(SHAM) Fischer rats. HF was induced by myocardial infarction and documented using echocardiographic, invasive, and postmortem measures. The severity of HF was similar in Y(HF) and A(HF) rats. SND responses to heating were attenuated in Y(HF) compared with Y(SHAM) rats, demonstrating an effect of HF on SND regulation in young rats. In contrast, A(HF) and A(SHAM) rats demonstrated similar SND responses to heating, suggesting a prominent influence of age on SND regulation in A(HF) rats. Splenic SND and MAP responses to heating were similar in Y(HF), A(HF), and A(SHAM) rats, indicating that the imposition of HF in young rats changes the regulatory status of these variables to one consistent with aged rats. These data suggest that the effect of HF on SND regulation to hyperthermia is age dependent.

Effectiveness of an Interventional Program to Improve Blood Pressure Control in Hypertensive Patients at High Risk for Developing Heart Failure: HEROIC study

The Efectividad de un Programa de Intervención en el Control de la Presión Arterial de los Hipertensos en Riesgo de Desarrollar Insuficiencia Cardiaca (HEROIC) study was designed to assess whether an educational program for primary care physicians could improve blood pressure (BP) control in hypertensive patients at high risk for developing heart failure. The program contained a combination of educational training (live group sessions or online training) and information feedback. Two hundred twenty-six physicians completed the program and provided valid data in 2489 patients before and 2168 after 1 year. There was a small but significant reduction of -1.1 mm Hg (P=.009) in systolic BP and a higher proportion of patients achieved their BP target (13.6% vs 15.6%, P=.055). Thus, the authors concluded that there was a slight improvement in BP control after the educational program, but this change was not sufficient to avoid development of heart failure. More complex and intensive programs are needed for this type of prevention.

Fully wireless implantable cardiovascular pressure monitor integrated with a medical stent

This paper presents a fully wireless cardiac pressure sensing system. Food and Drug Administration (FDA) approved medical stents are explored as radiating structures to support simultaneous transcutaneous wireless telemetry and powering. An application-specific integrated circuit (ASIC), designed and fabricated using the Texas Instruments 130-nm CMOS process, enables wireless telemetry, remote powering, voltage regulation, and processing of pressure measurements from a microelectromechanical systems (MEMS) capacitive sensor. This paper demonstrates fully wireless-pressure-sensing functionality with an external 35-dB.m RF powering source across a distance of 10 cm. Measurements in a regulated pressure chamber demonstrate the ability of the cardiac system to achieve pressure resolutions of 0.5 mmHg over a range of 0-50 mmHg using a channel data-rate of 42.2 kb/s.

Changes in cardiovascular hospitalization and comorbidity of heart failure in the United States: findings from the National Hospital Discharge Surveys 1980-2006

OBJECTIVE

This study aimed to update the long-term trend of coronary heart disease (CHD), cerebrovascular disease (CBVD), and heart failure (HF) hospitalization rates and HF comorbidity among adults aged 65 and older in the United States.

METHODS

Data from the National Hospital Discharge Surveys between 1980 and 2006 were used. CHD, CBVD, and HF were defined using the principal (first-listed) diagnosis of disease at hospital discharge according to the ICD-9-CM code. Census estimated population data (2000) were used to estimate age and gender-specific hospitalization rates.

RESULTS

Age-adjusted CHD and CBVD hospitalization rates have significantly decreased between 1980 and 2006, with an estimated annual decrease rate of 2.24% for CHD and 1.55% for CBVD in men, and 2.36% for CHD and 1.34% for CBVD in women. However, the absolute numbers of CHD and CBVD hospitalization continued to increase partly because of the aging population. Furthermore, HF hospitalization rates have significantly increased with an estimated annual rate increase of 1.20% in men and 1.55% in women between 1980 and 2006. Of six selected co-morbidities, about 50% in men and 40% in women with HF had a coexisting disease of CHD, followed by chronic obstructive pulmonary disease, diabetes mellitus, renal failure, and pneumonia.

CONCLUSIONS

While the burden of CHD and CBVD remains the major public health problem, HF has emerged as a new challenge in cardiovascular disease control, characterized by increased trends of HF hospitalization and increased comorbidities from major diseases.

Neurohormonal regulation of cardiac ion channels in chronic heart failure

Alteration of neurohormonal homeostasis is a hallmark of the pathophysiology of chronic heart failure (CHF). In particular, overactivation of the renin-angiotensin-aldosterone system and the sympathetic catecholaminergic system is consistently observed. Chronic overactivation of these hormonal pathways leads to a detrimental arrhythmogenic remodeling of cardiac tissue due to dysregulation of cardiac ion channels. Sudden cardiac death resulting from ventricular arrhythmias is a major cause of mortality in patients with CHF. All the drug classes known to reduce mortality in patients with CHF are neurohormonal blockers. The aim of this review was to provide an overview of how cardiac ion channels are regulated by hormones known to play a central role in the pathogenesis of CHF.

A community model of group rehabilitation for older patients with chronic heart failure: A pilot study

PURPOSE

The aim of this study was to develop and evaluate a community-based programme for heart failure patients, with emphasis on exercise and education.

METHOD

In a before-and-after trial, subjects with heart failure underwent a 12-week group programme comprising of exercise, education and mutual support. Outcome measures included subjects' compliance and views of the programme, knowledge related to disease management, physical parameters (symptoms, exercise tolerance, muscle strength) and psychosocial well-being (using generic and disease-specific tools). A focus group was held and participants' feedback noted.

RESULTS

Overall patient compliance and satisfaction rate was high. Significant changes were observed in knowledge, physical performance and psychosocial parameters. Subjects' feedback following the programme was generally positive.

CONCLUSIONS

This pilot study shows that a group programme for heart failure patients is feasible, acceptable and improved physical status and quality of life. It can be a useful model in the management of chronic disease in the community.

Recent advances in the application of computational mechanics to the diagnosis and treatment of cardiovascular disease

During the last 30 years, research into the pathogenesis and progression of cardiovascular disease has had to employ a multidisciplinary approach involving a wide range of subject areas, from molecular and cell biology to computational mechanics and experimental solid and fluid mechanics. In general, research was driven by the need to provide answers to questions of critical importance for disease management. Ongoing improvements in the spatial resolution of medical imaging equipment coupled to an exponential growth in the capacity, flexibility and speed of computational techniques have provided a valuable opportunity for numerical simulations and complex experimental techniques to make a contribution to improving the diagnosis and clinical management of many forms of cardiovascular disease. This paper contains a review of recent progress in the numerical simulation of cardiovascular mechanics, focusing on three particular areas: patient-specific modeling and the optimization of surgery in pediatric cardiology, evaluating the risk of rupture in aortic aneurysms, and noninvasive characterization of intraventricular flow in the management of heart failure.

The relationship between self-care and health status domains in Thai patients with heart failure

BACKGROUND

Little is known about the relationship between self-care in heart failure (HF) and outcomes like health status. The purpose of this study was to describe the relationship between HF self-care and Short Form-36 (SF-36) health status domains.

METHODS AND RESULTS

A secondary analysis of cross-sectional data collected on 400 HF patients living in southern Thailand was completed using bivariate comparisons and hierarchical multiple regression modeling. Thai population norm-based SF-36 scores and Self-Care of Heart Failure Index (SCHFI) scores were used in the analysis. The sample was in older adulthood (65.7 +/- 13.8 years), a slight majority of subjects were male (52%); the majority of subjects (62%) had class III or IV HF. Each health domain was low in this sample compared to the general population. SCHFI maintenance and confidence scores were correlated significantly with each health status domain. SCHFI scores explained a significant amount of variance all domains, both in bivariate and multivariate models, except social functioning. In multivariate models, higher levels of self-care were associated with better health in certain domains, but only when both SCFHI management and confidence were high.

CONCLUSION

Improving HF self-care may be a mechanism through which future interventions can improve health in this population.

Health-related quality of life in unselected outpatients with heart failure across Spain in two different health care levels. Magnitude and determinants of impairment: the INCA study

AIMS

To assess health-related quality of life (HRQL) in Spanish outpatients with chronic heart failure (CHF).

METHODS

Cross-sectional study carried out in a sample of CHF patients (echocardiography was performed in all of them) followed either in Primary Care (PC) centres or Cardiology outpatient clinics throughout Spain. HRQL was evaluated using the EuroQol 5D (EQ-5D) and Minnesota Living with Heart Failure (MLWHF) Questionnaire.

RESULTS

The study subjects were 2161 CHF patients (1412 PC; 749 Cardiology). Patients were older and had more severe disease in PC than in Cardiology settings. Their HRQL scores were likewise worse. After adjusting for clinical variables, the differences in global and physical MLWHF disappeared, but persisted to a smaller degree in EQ-5D and mental MLWHF. HRQL was worse than in a representative sample of the Spanish population and in other chronic conditions such as rheumatoid arthritis or type 2 diabetes, being only comparable to severe chronic obstructive pulmonary disease (COPD).

CONCLUSION

All domains of HRQL were significantly impaired in CHF patients. Differences found in HRQL between PC and Cardiology should possibly be attributed to a large extent to the different clinical characteristics of the patients attended. In spite of the differences between EQ-5D and MLWHF, our results suggest that both questionnaires adequately reflect the severity of the disease.

Accuracy of a heart failure diagnosis in administrative registers

BACKGROUND

The incidence of heart failure is frequently reported using hospital discharge diagnoses. The specificity of a diagnosis has been shown to be high but the sensitivity of a reported diagnosis is unknown.

PURPOSE

To study the accuracy of a heart failure diagnosis reported to the Danish National Patient Registers during routine clinical work.

METHODS

The patient population consisted of 3644 consecutive patients admitted to all departments in one hospital. Diagnoses reported to the National Patient Register were recorded. A study team evaluated each patient independently of routine care, performed an echocardiogram and evaluated whether clinical symptoms of heart failure were present. Heart failure was defined in accordance with current ESC guidelines as symptoms of heart failure and evidence of cardiac dysfunction.

RESULTS

A registered diagnosis of heart failure (n=126) carried a specificity of 99% and a sensitivity of 29% for all patients. The positive predictive value was 81%, the negative predictive value 90%.

CONCLUSION

The diagnosis of Heart Failure in the Danish National Registers is underreported, but very specific.

Impact of heart failure on hospital activity and healthcare costs in Belgium

Heart failure (HF) is a serious public health problem worldwide. It has a high prevalence, affects mainly the elderly and causes high mortality or disability with high economic costs. The aim of the present study was to calculate the number of admissions for HF, the total in-hospital stay, the mean length of in-hospital stay and the in-hospital costs due to HF in Belgium. Retrospective analysis of data from the national hospital registration system provided the following results. In 2001, there were 19,398 admissions with HF as a primary diagnosis, with a total in-hospital stay of 286,938 days. The mean in-hospital stay for HF was 14.8 days. The total in-hospital cost of HF as a primary diagnosis was euro 94,113,827, representing 1.8% of the total hospital expenditure. The limitations of this study are its mere focus on admissions and their characteristics in 2001, and the use of a retrospective analysis. Nevertheless, it led to the conclusion that HF was responsible for a significant number of in-hospital days, with a significant impact on healthcare costs in Belgium.

Cardiovascular disease: strategies for risk assessment and modification

Cardiovascular disease is the leading cause of death among men and women in the United States. Silent myocardial ischemia, defined as documentation of ischemia in the absence of angina or anginal equivalents, affects up to 4 million Americans and carries a poor prognosis. The assessment of the presence of subclinical coronary atherosclerosis affords an opportunity to identify patients who may be at risk for coronary artery disease over the long term. In addition to traditional risk factors (such as lipid parameters, diabetes, hypertension, smoking, and age), a variety of novel factors (such as lipoprotein[a], homocysteine, and C-reactive protein) may enhance assessment of risk in specific populations. Risk modification should be aimed at achieving recommended levels of lipids and blood pressure, reducing obesity, facilitating optimal management of diabetes and the metabolic syndrome, and encouraging smoking cessation and physical activity. Clinicians should be knowledgeable regarding the application of national guidelines for the reduction of cardiovascular risk so as to maximize the prospects for both the primary and secondary prevention of coronary artery disease and associated adverse outcomes.

Left ventricular structure and function: basic science for cardiac imaging

The myofiber geometry of the left ventricle (LV) changes gradually from a right-handed helix in the subendocardium to a left-handed helix in the subepicardium. In this review, we associate the LV myofiber architecture with emerging concepts of the electromechanical sequence in a beating heart. We discuss: 1) the morphogenesis and anatomical arrangement of muscle fibers in the adult LV; 2) the sequence of depolarization and repolarization; 3) the physiological inhomogeneity of transmural myocardial mechanics and the apex-to-base sequence of longitudinal and circumferential deformation; 4) the sequence of LV rotation; and 5) the link between LV deformation and the intracavitary flow direction observed during each phase of the cardiac cycle. Integrating the LV structure with electrical activation and motion sequences observed in vivo provides an understanding about the spatiotemporal sequence of regional myocardial performance that is essential for noninvasive cardiac imaging.