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Celik A, Surmeli AO, Demir M, Esen K, Camsari A. The diagnostic value of chest X-ray scanning by the help of Artificial Intelligence in Heart Failure (ART-IN-HF). Clin Cardiol 2023; 46:1562-1568. [PMID: 37654002 PMCID: PMC10716309 DOI: 10.1002/clc.24105] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Revised: 06/29/2023] [Accepted: 07/16/2023] [Indexed: 09/02/2023] Open
Abstract
BACKGROUND Typical signs of heart failure (HF), like increased cardiothoracic ratio (CTR) and pleural effusion, can be seen on X-ray. Artificial Intelligence (AI) can help in the early and quicker diagnosis of HF. OBJECTIVES The study's goal was to demonstrate that the AI interpretation of chest X-rays can assist the clinician in diagnosing HF. METHODS Patients older than 45 years were included in the study. The study analyzed 10 100 deidentified outpatient chest X-rays by AI algorithm. The AI-generated report was later verified by an independent radiologist. Patients with CTR > 0.5 and pleural effusion were marked as potential HF. Flagged patients underwent confirmatory tests, and those labeled as negative also underwent further investigations to rule out HF. RESULTS Out of 10 100, the AI algorithm detected 183 (1.8%) patients with increased CTR and pleural effusion on chest X-rays. One hundred and six out of 183 underwent diagnostic tests. Eighty-two (77%) out of 106 were diagnosed with HF according to current guidelines. From the remaining 9917 patients, 106 patients were randomly selected. Nine (8%) out of them were diagnosed with HF. The positive predictive value of AI for diagnosing HF is 77%, and the negative predictive value is 91%. More than half (54.9%) of newly diagnosed patients had HF with preserved ejection fraction. CONCLUSION HF is a risky condition with nonspecific symptoms that are difficult to diagnose, especially in the early stages. Using AI assistance for X-ray interpretation can be helpful for early diagnosis of HF especially HF with preserved ejection fraction.
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Affiliation(s)
- Ahmet Celik
- Department of CardiologyMersin University Medical FacultyMersinTurkey
| | - Ali Orcun Surmeli
- Department of CardiologyMersin University Medical FacultyMersinTurkey
| | - Mustafa Demir
- Department of CardiologyMersin University Medical FacultyMersinTurkey
| | - Kaan Esen
- Department of RadiologyMersin University Medical FacultyMersinTurkey
| | - Ahmet Camsari
- Department of CardiologyMersin University Medical FacultyMersinTurkey
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Characterizing Canadian long-term care home consumed foods and their inflammatory potential: a secondary analysis. BMC Public Health 2023; 23:261. [PMID: 36747181 PMCID: PMC9903425 DOI: 10.1186/s12889-022-14934-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 12/22/2022] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Nutrient dense food that supports health is a goal of food service in long-term care (LTC). The objective of this work was to characterize the "healthfulness" of foods in Canadian LTC and inflammatory potential of the LTC diet and how this varied by key covariates. Here, we define foods to have higher "healthfulness" if the are in accordance with the evidence-based 2019 Canada's Food Guide, or with comparatively lower inflammatory potential. METHODS We conducted a secondary analysis of the Making the Most of Mealtimes dataset (32 LTC homes; four provinces). A novel computational algorithm categorized food items from 3-day weighed food records into 68 expert-informed categories and Canada's Food Guide (CFG) food groups. The dietary inflammatory potential of these food sources was assessed using the Dietary Inflammatory Index (DII). Comparisons were made by sex, diet texture, and nutritional status. RESULTS Consumption patterns using expert-informed categories indicated no single protein or vegetable source was among the top 5 most commonly consumed foods. In terms of CFG's groups, protein food sources (i.e., foods with a high protein content) represented the highest proportion of daily calorie intake (33.4%; animal-based: 31.6%, plant-based: 1.8%), followed by other foods (31.3%) including juice (9.8%), grains (25.0%; refined: 15.0%, whole: 10.0%), and vegetables/fruits (10.3%; plain: 4.9%, with additions: 5.4%). The overall DII score (mean, IQR) was positive (0.93, 0.23 to 1.75) indicating foods consumed tend towards a pro-inflammatory response. DII was significantly associated with sex (female higher; p<0.0001), and diet (minced higher; p=0.036). CONCLUSIONS "Healthfulness" of Canadian LTC menus may be enhanced by lowering inflammatory potential to support chronic disease management through further shifts from refined to whole grains, incorporating more plant-based proteins, and moving towards serving plain vegetables and fruits. However, there are multiple layers of complexities to consider when optimising foods aligned with the CFG, and shifting to foods with anti-inflammatory potential for enhanced health benefits, while balancing nutrition and ensuring sufficient food and fluid intake to prevent or treat malnutrition.
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Welsh P, Campbell RT, Mooney L, Kimenai DM, Hayward C, Campbell A, Porteous D, Mills NL, Lang NN, Petrie MC, Januzzi JL, McMurray JJ, Sattar N. Reference Ranges for NT-proBNP (N-Terminal Pro-B-Type Natriuretic Peptide) and Risk Factors for Higher NT-proBNP Concentrations in a Large General Population Cohort. Circ Heart Fail 2022; 15:e009427. [PMID: 36098049 PMCID: PMC9561238 DOI: 10.1161/circheartfailure.121.009427] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 07/11/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Demographic differences in expected NT-proBNP (N-terminal pro-B-type natriuretic peptide) concentration are not well established. We aimed to establish reference ranges for NT-proBNP and explore the determinants of moderately elevated NT-proBNP under the universal definition of heart failure criteria. METHODS This is a cross-sectional study. NT-proBNP was measured in serum from 18 356 individuals without previous cardiovascular disease in the Generation Scotland Scottish Family Health Study. Age- and sex-stratified medians and 97.5th centiles were generated. Sex stratified risk factors for moderately elevated NT-proBNP (≥125 pg/mL) were investigated. RESULTS In males, median (97.5th centile) NT-proBNP concentration at age <30 years was 21 (104) pg/mL, rising to 38 (195) pg/ml at 50 to 59 years, and 281 (6792) pg/mL at ≥80 years. In females, median NT-proBNP at age <30 years was 51 (196) pg/mL, 66 (299) pg/mL at 50 to 59 years, and 240 (2704) pg/mL at ≥80 years. At age <30 years, 9.8% of females and 1.4% of males had elevated NT-proBNP, rising to 76.5% and 81.0%, respectively, at age ≥80 years. After adjusting for risk factors, an NT-proBNP ≥125 pg/mL was more common in females than males (OR, 9.48 [95% CI, 5.60-16.1]). Older age and smoking were more strongly associated with elevated NT-proBNP in males than in females (Psex interaction <0.001, 0.07, respectively). Diabetes was inversely associated with odds of elevated NT-proBNP in females only (Psex interaction=0.007). CONCLUSIONS An NT-proBNP ≥125 pg/mL is common in females without classical cardiovascular risk factors as well as older people. If NT-proBNP becomes widely used for screening in the general population, interpretation of NT-proBNP levels will require that age and sex-specific thresholds are used to identify patients with potential pathophysiology.
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Affiliation(s)
- Paul Welsh
- School of Cardiovascular and Metabolic Health, University of Glasgow, United Kingdom (P.W., R.T.C., L.M., N.N.L., M.C.P., J.J.V.M., N.S.)
| | - Ross T. Campbell
- School of Cardiovascular and Metabolic Health, University of Glasgow, United Kingdom (P.W., R.T.C., L.M., N.N.L., M.C.P., J.J.V.M., N.S.)
| | - Leanne Mooney
- School of Cardiovascular and Metabolic Health, University of Glasgow, United Kingdom (P.W., R.T.C., L.M., N.N.L., M.C.P., J.J.V.M., N.S.)
| | - Dorien M. Kimenai
- British Heart Foundation Centre for Cardiovascular Science (D.M.K., N.L.M.), University of Edinburgh, United Kingdom
| | - Caroline Hayward
- Medical Research Council Human Genetics Unit (C.H.), University of Edinburgh, United Kingdom
| | - Archie Campbell
- Institute of Genetics and Cancer (A.C., D.P.), University of Edinburgh, United Kingdom
| | - David Porteous
- Institute of Genetics and Cancer (A.C., D.P.), University of Edinburgh, United Kingdom
| | - Nicholas L. Mills
- British Heart Foundation Centre for Cardiovascular Science (D.M.K., N.L.M.), University of Edinburgh, United Kingdom
- Usher Institute (N.L.M.), University of Edinburgh, United Kingdom
| | - Ninian N. Lang
- School of Cardiovascular and Metabolic Health, University of Glasgow, United Kingdom (P.W., R.T.C., L.M., N.N.L., M.C.P., J.J.V.M., N.S.)
| | - Mark C. Petrie
- School of Cardiovascular and Metabolic Health, University of Glasgow, United Kingdom (P.W., R.T.C., L.M., N.N.L., M.C.P., J.J.V.M., N.S.)
| | - James L. Januzzi
- Cardiology Division, Massachusetts General Hospital, Boston (J.L.J.)
- Harvard Medical School, Boston, MA (J.L.J.)
| | - John J.V. McMurray
- School of Cardiovascular and Metabolic Health, University of Glasgow, United Kingdom (P.W., R.T.C., L.M., N.N.L., M.C.P., J.J.V.M., N.S.)
| | - Naveed Sattar
- School of Cardiovascular and Metabolic Health, University of Glasgow, United Kingdom (P.W., R.T.C., L.M., N.N.L., M.C.P., J.J.V.M., N.S.)
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Sunderraj A, Cho C, Cai X, Gupta S, Mehta R, Isakova T, Leaf DE, Srivastava A. Modulation of the Association Between Age and Death by Risk Factor Burden in Critically Ill Patients With COVID-19. Crit Care Explor 2022; 4:e0755. [PMID: 36050992 PMCID: PMC9426819 DOI: 10.1097/cce.0000000000000755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Older age is a key risk factor for adverse outcomes in critically ill patients with COVID-19. However, few studies have investigated whether preexisting comorbidities and acute physiologic ICU factors modify the association between age and death. DESIGN Multicenter cohort study. SETTING ICUs at 68 hospitals across the United States. PATIENTS A total of 5,037 critically ill adults with COVID-19 admitted to ICUs between March 1, 2020, and July 1, 2020. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The primary exposure was age, modeled as a continuous variable. The primary outcome was 28-day inhospital mortality. Multivariable logistic regression tested the association between age and death. Effect modification by the number of risk factors was assessed through a multiplicative interaction term in the logistic regression model. Among the 5,037 patients included (mean age, 60.9 yr [± 14.7], 3,179 [63.1%] male), 1,786 (35.4%) died within 28 days. Age had a nonlinear association with 28-day mortality (p for nonlinearity <0.001) after adjustment for covariates that included demographics, preexisting comorbidities, acute physiologic ICU factors, number of ICU beds, and treatments for COVID-19. The number of preexisting comorbidities and acute physiologic ICU factors modified the association between age and 28-day mortality (p for interaction <0.001), but this effect modification was modest as age still had an exponential relationship with death in subgroups stratified by the number of risk factors. CONCLUSIONS In a large population of critically ill patients with COVID-19, age had an independent exponential association with death. The number of preexisting comorbidities and acute physiologic ICU factors modified the association between age and death, but age still had an exponential association with death in subgroups according to the number of risk factors present. Additional studies are needed to identify the mechanisms underpinning why older age confers an increased risk of death in critically ill patients with COVID-19.
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Affiliation(s)
- Ashwin Sunderraj
- Graduate Medical Education, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Chloe Cho
- Undergraduate Medical Education, Northwestern University, Evanston, IL
| | - Xuan Cai
- Division of Nephrology & Hypertension, Center for Translational Metabolism and Health, Institute of Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Shruti Gupta
- Department of Medicine, Division of Renal Medicine, Brigham and Women's Hospital, Boston, MA
| | - Rupal Mehta
- Division of Nephrology & Hypertension, Center for Translational Metabolism and Health, Institute of Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Tamara Isakova
- Division of Nephrology & Hypertension, Center for Translational Metabolism and Health, Institute of Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - David E Leaf
- Department of Medicine, Division of Renal Medicine, Brigham and Women's Hospital, Boston, MA
| | - Anand Srivastava
- Division of Nephrology & Hypertension, Center for Translational Metabolism and Health, Institute of Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
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Chandramouli C, Stewart S, Almahmeed W, Lam CSP. Clinical implications of the universal definition for the prevention and treatment of heart failure. Clin Cardiol 2022; 45 Suppl 1:S2-S12. [PMID: 35789016 PMCID: PMC9254673 DOI: 10.1002/clc.23842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 04/27/2022] [Indexed: 11/16/2022] Open
Abstract
The diagnosis of heart failure (HF) primarily relies on signs and symptoms that are neither sensitive nor specific. This impedes timely diagnosis and delays effective therapies or interventions, despite the availability of several evidence-based treatments for HF. Through monumental collaborative efforts from representatives of HF societies worldwide, the universal definition of HF was published in 2021, to provide the necessary standardized framework required for clinical management, clinical trials, and research. This review elaborates the key concepts of the new universal definition of HF, highlighting the key merits and potential avenues, which can be nuanced further in future iterations. We also discuss the key implications of the universal definition document from the perspectives of various stakeholders within the healthcare framework, including patients, care providers, system/payers and policymakers.
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Affiliation(s)
- Chanchal Chandramouli
- National Heart Centre SingaporeSingaporeSingapore
- Duke‐National University of SingaporeSingaporeSingapore
| | - Simon Stewart
- Torrens University AustraliaAdelaideSouth AustraliaAustralia
- University of GlasgowGlasgowUK
- Institute of Health ResearchUniversity of Notre Dame AustraliaFremantleNew South WalesAustralia
| | - Wael Almahmeed
- Institute of Cardiac Science, Sheikh Khalifa Medical CityAbu DhabiUnited Arab Emirates
- Heart and Vascular Institute, Cleveland ClinicAbu DhabiUnited Arab Emirates
| | - Carolyn Su Ping Lam
- National Heart Centre SingaporeSingaporeSingapore
- Duke‐National University of SingaporeSingaporeSingapore
- University Medical Centre GroningenGroningenThe Netherlands
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Kahn M, Grayson AD, Chaggar PS, Ng Kam Chuen MJ, Scott A, Hughes C, Campbell NG. Primary care heart failure service identifies a missed cohort of heart failure patients with reduced ejection fraction. Eur Heart J 2021; 43:405-412. [PMID: 34508630 PMCID: PMC8825238 DOI: 10.1093/eurheartj/ehab629] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 07/05/2021] [Accepted: 08/27/2021] [Indexed: 01/09/2023] Open
Abstract
AIMS We explored whether a missed cohort of patients in the community with heart failure (HF) and left ventricular systolic dysfunction (LVSD) could be identified and receive treatment optimization through a primary care heart failure (PCHF) service. METHODS AND RESULTS PCHF is a partnership between Inspira Health, National Health Service Cardiologists and Medtronic. The PCHF service uses retrospective clinical audit to identify patients requiring a prospective face-to-face consultation with a consultant cardiologist for clinical review of their HF management within primary care. The service is delivered via five phases: (i) system interrogation of general practitioner (GP) systems; (ii) clinical audit of medical records; (iii) patient invitation; (iv) consultant reviews; and (v) follow-up. A total of 78 GP practices (864 194 population) have participated. In total, 19 393 patients' records were audited. HF register was 9668 (prevalence 1.1%) with 6162 patients coded with LVSD (prevalence 0.7%). HF case finder identified 9725 additional patients to be audited of whom 2916 patients required LVSD codes adding to the patient medical record (47% increase in LVSD). Prevalence of HF with LVSD increased from 0.7% to 1.05%. A total of 662 patients were invited for consultant cardiologist review at their local GP practice. The service found that within primary care, 27% of HF patients identified for a cardiologist consultation were eligible for complex device therapy, 45% required medicines optimization, and 47% of patients audited required diagnosis codes adding to their GP record. CONCLUSION A PCHF service can identify a missed cohort of patients with HF and LVSD, enabling the optimization of prognostic medication and an increase in device prescription.
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Affiliation(s)
- Matthew Kahn
- Cardiology Department, Liverpool Centre for Cardiovascular Science, Liverpool Heart and Chest Hospital NHS Foundation Trust, Thomas Drive, Liverpool L14 3PE, UK
| | - Antony D Grayson
- Inspira Health Ltd, Oriel House, 2-8 Oriel Road, Bootle, Liverpool L20 7EP, UK
| | - Parminder S Chaggar
- Cardiology Department, Royal Cornwall Hospitals NHS Trust, Treliske, Truro, Cornwall TR1 3LJ, UK
| | - Marie J Ng Kam Chuen
- Cardiology Department, Nottingham University Hospitals NHS Trust, Hucknall Road, Nottingham NG5 1PB, UK
| | - Alison Scott
- Medtronic Ltd, Building 9, Croxley Park, Hatters Lane, Watford WD18 8WW, UK
| | - Carol Hughes
- Inspira Health Ltd, Oriel House, 2-8 Oriel Road, Bootle, Liverpool L20 7EP, UK
| | - Niall G Campbell
- Cardiology Department, Institute of Cardiovascular Sciences, University of Manchester, Manchester University NHS Foundation Trust, Wythenshawe Hospital, Southmoor Road, Wythenshawe, Manchester M23 9LT, UK
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7
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Schlitzer J, Heppner HJ, Frohnhofen H. Reliability of the blood pressure response during performance of bedside Valsalva maneuver and association with NT-pBNP levels. Z Gerontol Geriatr 2021; 54:371-376. [PMID: 33533962 DOI: 10.1007/s00391-021-01849-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Accepted: 01/12/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Heart failure (HF) is common in older people. The diagnosis of HF, however, is difficult in older subjects, especially in settings without direct access to further diagnostics. The type of blood pressure response during the performance of a Valsalva maneuver has been suggested as an easily applicable bedside test to detect HF; however, the reliability of this maneuver and the association with HF is unknown in geriatric patients. METHODS This study included 89 patients admitted for geriatric rehabilitation. Systolic blood pressure was taken while the patient performed a Valsalva maneuver. The systolic blood pressure response was classified as sinusoidal (type A), absent overshoot (type B) or square pattern (type C). To test interrater reliability systolic blood pressure response was evaluated independently by two investigators. The procedure was repeated after 1h to estimate test-retest reliability. Both investigators were blinded to the results of the other. Interrater reliability and test-retest reliability were calculated using Cohen's kappa. Blood samples for N‑terminal pro brain natriuretic peptide (NT-pBNP) were obtained on the morning the Valsalva maneuver was performed. RESULTS Blood pressure response was sinusoidal in 37 (42%), showed an absent overshoot in 17 (19%) and had a square wave pattern in 34 (38%) patients. Cohen's kappa was 0.911 (95% CI 0.837-0.985) for interrater reliability and 0.929 (95% CI 0. 0.862-0.996) for test-retest reliability. The interrater and test-retest agreement were 94% and 96%, respectively. The mean NT-pBNP plasma levels and the interquartile ranges (IQR) in subjects with types A, B and C blood pressure response pattern were 213 (153-324) pg/ml, 805 (622-1332) pg/ml and 3964 (2595-5906) pg/ml, respectively (p < 0.001). CONCLUSION The blood pressure response during a Valsalva maneuver shows an excellent reliability in older subjects. The type of response is associated with the NT-pBNP plasma level.
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Affiliation(s)
- J Schlitzer
- Department of Geriatrics, Kliniken Essen Mitte, Essen, Germany
| | - H J Heppner
- Department of Geriatrics, Helios Klinikum Schwelm, Schwelm, Germany.,Faculty of Health, Department of Medicine, University Witten-Herdecke, Witten, Germany
| | - H Frohnhofen
- Faculty of Health, Department of Medicine, University Witten-Herdecke, Witten, Germany. .,Department of Orthopedics and Accident Surgery, University-Hospital, Moorenstraße 5, 40225, Düsseldorf, Germany.
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8
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Health Care Use Before First Heart Failure Hospitalization. JACC-HEART FAILURE 2020; 8:1024-1034. [DOI: 10.1016/j.jchf.2020.07.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 07/21/2020] [Accepted: 07/24/2020] [Indexed: 11/21/2022]
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Optimisation of Heart Failure Management in Nursing Homes Using Point-of-Care Ultrasonography: Harmonious Trial Rationale and Design. Zdr Varst 2020; 59:128-136. [PMID: 32952713 PMCID: PMC7478089 DOI: 10.2478/sjph-2020-0017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2019] [Accepted: 05/07/2020] [Indexed: 12/28/2022] Open
Abstract
Introduction Heart failure is common in the nursing home population and presents many diagnostic and therapeutic challenges. Point-of-care ultrasonography is a bedside method that can be used to assess volume status more reliably than clinical examination. This trial was conceived to test whether point-of-care ultrasonography-guided management improves heart failure outcomes among nursing home residents. Methods Nursing home residents with heart failure will be enrolled in a multi-centre, prospective, randomised controlled trial. Residents will first be screened for heart failure. Patients with heart failure will be randomised in 1:1 fashion into two groups. Nursing home physicians will adjust diuretic therapy according to volume status for six months. Point-of-care ultrasonography will be used in the test group and clinical examination in the control group. The primary endpoint will be heart failure deterioration, defined as a composite of any of the following four events: the need for an intravenous diuretic application, the need for an emergency service intervention, the need for unplanned hospitalisation for non-injury causes, or death from whatever cause. Expected results The expected prevalence of heart failure among nursing home residents is above 10%. Point-of-care ultrasonography-guided heart failure management will reduce the number of deteriorations of heart failure in the nursing home population. Conclusion This study will explore the usefulness of point-of-care ultrasonography for heart failure management in the nursing home population.
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Homar V, Mirosevic S, Svab I, Lainscak M. Natriuretic peptides for heart failure screening in nursing homes: a systematic review. Heart Fail Rev 2020; 26:1131-1140. [PMID: 32200491 DOI: 10.1007/s10741-020-09944-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
The high burden of heart failure in nursing-home populations is due to advanced age and comorbidities. Heart failure is often undiagnosed or misdiagnosed in this population and therefore remains untreated. We review the use of natriuretic peptide biomarkers for screening heart failure in nursing-home residents. The study was performed in accordance with recommendations from the Cochrane Collaboration using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement (PRISMA) and is registered in PROSPERO Register of Systematic Reviews. Databases PubMed, Embase, and Trip were searched from 2000 to March 2019, supplemented by hand-searching of references. Studies investigating the nursing-home population were included. The prevalence of heart failure among nursing-home residents was higher than in the general population of comparable age (23% vs 10%, respectively). The rate of misdiagnosis in nursing homes ranged from 25 to 76%. NT-proBNP was the most commonly used natriuretic peptide biomarker for heart failure screening. The mean value of NT-proBNP was significantly higher in residents with heart failure than in residents overall (pooled means of 2409 pg/mL vs 1074 pg/mL, respectively). In comparison with current guidelines, the proposed cut-off values for ruling out heart failure were higher in the analyzed studies, with ranges of 230-760 pg/mL for NT-proBNP and 50-115 pg/mL for BNP. NT-proBNP and BNP are used for screening heart failure in the nursing-home population. The current screening cut-off values are probably too low for use in nursing homes. Our most conservative estimation for ruling out heart failure is an NT-proBNP cut-off value of 230 pg/mL.
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Affiliation(s)
- Vesna Homar
- Department of Family Medicine, Faculty of Medicine, University of Ljubljana, 56 Poljanski nasip, 1000, Ljubljana, Slovenia. .,Community Health Centre Vrhnika, Vrhnika, Slovenia.
| | - Spela Mirosevic
- Department of Family Medicine, Faculty of Medicine, University of Ljubljana, 56 Poljanski nasip, 1000, Ljubljana, Slovenia
| | - Igor Svab
- Department of Family Medicine, Faculty of Medicine, University of Ljubljana, 56 Poljanski nasip, 1000, Ljubljana, Slovenia
| | - Mitja Lainscak
- Department of Family Medicine, Faculty of Medicine, University of Ljubljana, 56 Poljanski nasip, 1000, Ljubljana, Slovenia.,Division of Cardiology, General Hospital Murska Sobota, Murska Sobota, Slovenia
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Belmin J, Donadio C, Jarzebowski W, Genranmayeh K, Valembois L, Lafuente-Lafuente C. The value of B-type natriuretic peptide plasma concentrations in very old people with chronic peripheral oedema. Arch Cardiovasc Dis 2020; 113:332-340. [PMID: 32151555 DOI: 10.1016/j.acvd.2019.12.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 12/22/2019] [Accepted: 12/30/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND Chronic peripheral oedema is frequent in old patients, and very often results from multiple causes. AIM To investigate whether determination of B-type natriuretic peptide plasma concentration helps with the diagnosis of chronic peripheral oedema aetiologies. METHODS This was a cross-sectional observational study conducted in geriatric hospital wards (intermediate and long-term care) on consecutive in-hospital patients aged>75 years with chronic peripheral oedema and no dyspnoea. From medical history, physical examination, routine biological tests and chest radiography, two investigators determined the aetiologies of oedema, with special attention paid to recognizing chronic heart failure. This reference diagnosis was compared with the clinical diagnosis mentioned in the medical chart. Brain natriuretic peptide plasma concentrations were measured soon after the investigators' visit. RESULTS Among the 141 patients (113 women and 28 men) aged 86±6 years, a single aetiology was identified in 53 (38%), and multiple aetiologies in 84 (60%). The main aetiologies were venous insufficiency (69%), chronic heart failure (43%), hypoproteinaemia (38%) and drug-induced oedema (26%). Chronic heart failure was frequently misdiagnosed by attending clinicians (missed in 18 cases and wrongly diagnosed in 14 cases). Brain natriuretic peptide concentration was significantly higher in patients with chronic heart failure than in those without: median (interquartile range) 490 (324-954) versus 137 (79-203) pg/mL, respectively (P<0.0001). The receiver operating characteristic curve showed that a concentration of 274pg/mL was appropriate for diagnosing chronic heart failure, with a specificity of 0.89 and a sensitivity of 0.82. Brain natriuretic peptide concentrations above this cut-off were significantly and independently associated with the diagnosis of chronic heart failure. CONCLUSIONS Chronic heart failure is frequently misdiagnosed in old patients with chronic peripheral oedema, and B-type natriuretic peptide plasma concentration helped to improve the diagnosis of this condition and identify chronic heart failure.
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Affiliation(s)
- Joël Belmin
- Service de Gériatrie, hôpital Charles-Foix, hôpitaux universitaires Pitié-Salpêtrière-Charles Foix, 7, avenue de la République, 94200 Ivry-sur-Seine, France; Sorbonne Université (UPMC), 75013 Paris, France.
| | - Cristiano Donadio
- Service de Gériatrie, hôpital Charles-Foix, hôpitaux universitaires Pitié-Salpêtrière-Charles Foix, 7, avenue de la République, 94200 Ivry-sur-Seine, France
| | - Witold Jarzebowski
- Service de Gériatrie, hôpital Charles-Foix, hôpitaux universitaires Pitié-Salpêtrière-Charles Foix, 7, avenue de la République, 94200 Ivry-sur-Seine, France
| | - Kamran Genranmayeh
- Service de Gériatrie, hôpital Charles-Foix, hôpitaux universitaires Pitié-Salpêtrière-Charles Foix, 7, avenue de la République, 94200 Ivry-sur-Seine, France
| | - Lucie Valembois
- Service de Gériatrie, hôpital Charles-Foix, hôpitaux universitaires Pitié-Salpêtrière-Charles Foix, 7, avenue de la République, 94200 Ivry-sur-Seine, France
| | - Carmelo Lafuente-Lafuente
- Service de Gériatrie, hôpital Charles-Foix, hôpitaux universitaires Pitié-Salpêtrière-Charles Foix, 7, avenue de la République, 94200 Ivry-sur-Seine, France; Sorbonne Université (UPMC), 75013 Paris, France
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12
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van Mourik Y, Rutten FH, Bertens LC, Cramer MJ, Lammers JWJ, Gohar A, Reitsma JB, Moons KG, Hoes AW. Clinical research study implementation of case-finding strategies for heart failure and chronic obstructive pulmonary disease in the elderly with reduced exercise tolerance or dyspnea: A cluster randomized trial. Am Heart J 2020; 220:73-81. [PMID: 31790904 DOI: 10.1016/j.ahj.2019.08.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2019] [Accepted: 08/27/2019] [Indexed: 11/25/2022]
Abstract
BACKGROUND Heart failure (HF) and chronic obstructive pulmonary disease (COPD) often remain undiagnosed in older individuals, although both disorders inhibit functionality and impair health. The aim of the study was to assess the effectiveness of a case-finding strategy of these disorders. METHODS This is a clustered randomized trial; 18 general practices from the vicinity of Utrecht, the Netherlands, were randomly allocated to a case-finding strategy or usual care. Multimorbid community subjects (≥65 years) with dyspnea or reduced exercise tolerance were eligible for inclusion. The case-finding strategy consisted of history taking, physical examination, blood tests, electrocardiography, spirometry, and echocardiography. Subsequent treatment decisions were at the discretion of the general practitioner. Questionnaires regarding health status and functionality were filled out at baseline and after 6 months of follow-up. Information regarding changes in medication and health care use during the 6 months follow-up was extracted. RESULTS A total of 829 participants were randomized: 389 in the case-finding strategy group and 440 in the usual care group. More patients in the case-finding group received a new diagnosis of HF or COPD than the usual care group (cumulative incidence 34% vs 2% and 17% vs. 2%, respectively). Scores for health status, functionality, and health care use were similar between the 2 strategies after 6 months of follow-up. CONCLUSIONS A case-finding strategy applied in primary care to multimorbid older people with dyspnea or reduced exercise tolerance resulted in a number of new diagnoses of HF and COPD but did not result in short-term improvement of health status compared to usual care.
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13
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Barandiarán Aizpurua A, Sanders-van Wijk S, Brunner-La Rocca HP, Henkens M, Heymans S, Beussink-Nelson L, Shah SJ, van Empel VPM. Validation of the HFA-PEFF score for the diagnosis of heart failure with preserved ejection fraction. Eur J Heart Fail 2019; 22:413-421. [PMID: 31472035 DOI: 10.1002/ejhf.1614] [Citation(s) in RCA: 103] [Impact Index Per Article: 20.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Revised: 08/13/2019] [Accepted: 08/20/2019] [Indexed: 12/20/2022] Open
Abstract
AIMS Diagnosing heart failure with preserved ejection fraction (HFpEF) is challenging. The newly proposed HFA-PEFF algorithm entails a stepwise approach. Step 1, typically performed in the ambulatory setting, establishes a pre-test likelihood. The second step calculates a score based on echocardiography and natriuretic peptides. The aim of this study is to validate the diagnostic value and establish the clinical impact of the second step of the HFA-PEFF score. METHODS AND RESULTS The second step of the HFA-PEFF score was evaluated in two independent, prospective cohorts, i.e. the Maastricht cohort (228 HFpEF patients and 42 controls) and the Northwestern Chicago cohort (459 HFpEF patients). In Maastricht, the HFA-PEFF score categorizes 11 (4%) of the total cohort with suspected HFpEF in the low-likelihood (0-1 points) and 161 (60%) in the high-likelihood category (5-6 points). A high HFA-PEFF score can rule in HFpEF with high specificity (93%) and positive predictive value (98%). A low score can rule out HFpEF with a sensitivity of 99% and a negative predictive value of 73%. The diagnostic accuracy of the score is 0.90 (0.84-0.96), by the area under the curve of the receiver operating characteristic curve. However, 98 (36%) are classified in the intermediate-likelihood category, where additional testing is advised. The distribution of the score shows a similar pattern in the Northwestern (Chicago) and Maastricht HFpEF patients (53% vs. 65% high, 43% vs. 34% intermediate, 4.8% vs. 1.3% low). CONCLUSION This study validates and characterizes the HFA-PEFF score in two independent, well phenotyped cohorts. We demonstrate that the HFA-PEFF score is helpful in clinical practice for the diagnosis of HFpEF.
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Affiliation(s)
- Arantxa Barandiarán Aizpurua
- Department of Cardiology, Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands.,Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands
| | - Sandra Sanders-van Wijk
- Department of Cardiology, Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands.,Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands.,Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Hans-Peter Brunner-La Rocca
- Department of Cardiology, Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands.,Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands
| | - Michiel Henkens
- Department of Cardiology, Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands.,Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands
| | - Stephane Heymans
- Department of Cardiology, Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands.,Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands.,Department of Cardiovascular Research, University of Leuven, Leuven, Belgium.,Netherlands Heart Institute (ICIN), Utrecht, The Netherlands
| | | | - Sanjiv J Shah
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Vanessa P M van Empel
- Department of Cardiology, Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands.,Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands
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14
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Kańtoch A, Gryglewska B, Wójkowska-Mach J, Heczko P, Grodzicki T. Treatment of Cardiovascular Diseases Among Elderly Residents of Long-term Care Facilities. J Am Med Dir Assoc 2019; 19:428-432. [PMID: 29402648 DOI: 10.1016/j.jamda.2017.12.102] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Accepted: 12/29/2017] [Indexed: 01/02/2023]
Abstract
BACKGROUND The prevalence of cardiovascular diseases among nursing home residents is high but little is known whether pharmacologic therapy recommended by actual medication guidelines is followed by facility's staff. AIM To evaluate the adherence to actual guidelines for treatment of cardiovascular diseases among older adult residents of long-term care (LTC) facilities. MATERIAL AND METHODS The cross-sectional study was performed from December 2009 to November 2010 among 189 elderly residents aged ≥60 years in 3 LTC facilities in Poland: 1 long-term care hospital (LTCH) and 2 nursing homes (NHs). The initial evaluation included analysis of medical documentation (all diagnosed diseases and used drugs), blood pressure (BP) measurements and performance of Mini Nutritional Assessment Short-Form (MNA-SF), Abbreviated Mental Test Score (AMTS), Activities of Daily Living (ADL) score, and Barthel Index. Prescribed medication for hypertension (HT), heart failure (HF), and coronary heart disease (CHD) were compared to current European Cardiology Society (ESC), and European Society of Hypertension (ESH) medication guidelines. Residents were divided into 3 subgroups: with HT, HF, and CHD. Results were presented as means and standard deviation. Groups were compared using Mann-Whitney U test for nonparametric data and chi-square test to assess differences in distribution of categorical variables. P values <.05 were considered statistically significant. RESULTS CHD was diagnosed among 114 residents (60.3%) but only 60.5% of them were treated with aspirin (ASA), 45.6% with beta-blockers (BBs), 60.5% with angiotensin-converting enzyme inhibitor (ACEI), and 24.6% with statins. HF observed in 75% of cases was treated by using ACEI (54.7%), BBs (45.3%), loop diuretics (LDs, 36%), mineralocorticoid-receptor antagonists (MRAs, 21.3%). HT was diagnosed among 98 study participants (51.9%) and in the majority of cases (76.6%) was well controlled (mean BP: 133.7 ± 17.6/73.8 ± 10.2 mmHg). The most popular antihypertensive drugs were ACEIs (77.6%), BBs (40.8%) and calcium channel blockers (CCBs, 26.5%) whereas thiazides, alpha-blockers (ABs), and angiotensin receptor blockers (ARBs) were used less frequently. CONCLUSION In summary, the study showed that insufficient treatment of cardiovascular diseases among elderly residents of LTC facilities could be a potential risk factor of poor prognosis.
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Affiliation(s)
- Anna Kańtoch
- Department of Internal Medicine and Gerontology, Faculty of Medicine, Jagiellonian University Medical College, University Hospital in Kraków, Kraków, Poland.
| | - Barbara Gryglewska
- Department of Internal Medicine and Gerontology, Faculty of Medicine, Jagiellonian University Medical College, University Hospital in Kraków, Kraków, Poland
| | - Jadwiga Wójkowska-Mach
- Department of Microbiology, Faculty of Medicine, Jagiellonian University Medical College, Kraków, Poland
| | - Piotr Heczko
- Department of Microbiology, Faculty of Medicine, Jagiellonian University Medical College, Kraków, Poland
| | - Tomasz Grodzicki
- Department of Internal Medicine and Gerontology, Faculty of Medicine, Jagiellonian University Medical College, University Hospital in Kraków, Kraków, Poland
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15
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Smeets M, Aertgeerts B, Mullens W, Penders J, Vercammen J, Janssens S, Vaes B. Optimising standards of care of heart failure in general practice the OSCAR-HF pilot study protocol. Acta Cardiol 2019; 74:371-379. [PMID: 30507291 DOI: 10.1080/00015385.2018.1507426] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Background: Heart failure (HF) imposes a burden for patients and health economics. General practitioners (GPs) are confronted with the broadest range of HF management. Although guidelines exist, they are not fully implemented in the Belgian health care system. Methods: We will conduct a non-randomised, non-controlled prospective observational trial (six months follow-up) to implement a multifaceted intervention in Belgian general practice to support GPs in the implementation of evidence-based HF guidelines. The multifaceted intervention consists of an audit and feedback method to detect previously unrecognised patients with HF and to increase awareness for proactive HF management, an NT-proBNP point-of-care test to improve detection and adequate diagnosis of patients with HF and a specialist HF nurse to assist GPs in the education of patients, optimisation of treatment and follow-up after hospitalisation. All patients aged 40 years and older with a confirmed diagnosis of HF by their GP based on the clinical audit are eligible for participation. The main objective of this pilot study is to evaluate the feasibility of this multifaceted intervention and the evolution of predefined quality indicators. We will measure the impact on HF diagnosis, medication optimisation, multidisciplinary follow-up and patients' quality of life after six months. Additionally, the experiences of GPs and investigators will be studied. Conclusions: Heart failure is an important health problem in which GPs play a key role. Therefore, we will evaluate the feasibility of a multifaceted intervention to optimise diagnosis as well as implement the guideline recommended therapies in patients with HF in general practice.
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Affiliation(s)
- Miek Smeets
- Department of Public Health and Primary Care, KU Leuven (KUL), Leuven, Belgium
| | - Bert Aertgeerts
- Department of Public Health and Primary Care, KU Leuven (KUL), Leuven, Belgium
| | - Wilfried Mullens
- Faculty of Medicine and Life Sciences, Biomedical Research Institute, Hasselt University, Diepenbeek, Belgium
- Department of Cardiology, Ziekenhuis Oost-Limburg (ZOL), Genk, Belgium
| | - Joris Penders
- Department of Clinical Biology, Ziekenhuis Oost-Limburg (ZOL), Genk, Belgium
- Faculty of Medicine and Life Sciences, Biomedical Research Institute, Hasselt University, Diepenbeek, Belgium
| | - Jan Vercammen
- Department of Cardiology, Ziekenhuis Oost-Limburg (ZOL), Genk, Belgium
| | - Stefan Janssens
- Department of Cardiovascular Diseases, Universitair Ziekenhuis Gasthuisberg, KU Leuven (KUL), Leuven, Belgium
| | - Bert Vaes
- Department of Public Health and Primary Care, KU Leuven (KUL), Leuven, Belgium
- Institute of Health and Society, Université Catholique de Louvain (UCL), Brussels, Belgium
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16
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Ali A, Bain S, Hicks D, Newland Jones P, Patel DC, Evans M, Fernando K, James J, Milne N, Viljoen A, Wilding J. SGLT2 Inhibitors: Cardiovascular Benefits Beyond HbA1c-Translating Evidence into Practice. Diabetes Ther 2019; 10:1595-1622. [PMID: 31290126 PMCID: PMC6778582 DOI: 10.1007/s13300-019-0657-8] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Indexed: 02/07/2023] Open
Abstract
Cardiovascular disease (CVD), including heart failure (HF), is a leading cause of morbidity and mortality in people with type 2 diabetes mellitus (T2DM). CVD and T2DM share common risk factors for development and progression, and there is significant overlap between the conditions in terms of worsening outcomes. In assessing the cardiovascular (CV) safety profiles of anti-diabetic drugs, sodium-glucose co-transporter-2 inhibitor (SGLT2i) therapies have emerged with robust evidence for reducing the risk of adverse CVD outcomes in people with T2DM who have either established CVD or are at risk of developing CVD. A previous consensus document from the Improving Diabetes Steering Committee has examined the potential role of SGLT2is in T2DM management and considered the risk-benefit profile of the class and the appropriate place for these medicines within the T2DM pathway. This paper builds on these findings and presents practical guidance for maximising the pleiotropic benefits of this class of medicines in people with T2DM in terms of reducing adverse CVD outcomes. The Improving Diabetes Steering Committee aims to offer evidence-based practical guidance for the use of SGLT2i therapies in people with T2DM stratified by CVD risk. This is of particular importance currently because some treatment guidelines have not been updated to reflect recent evidence from cardiovascular outcomes trials (CVOTs) and real-world studies that complement the CVOTs. The Improving Diabetes Steering Committee seeks to support healthcare professionals (HCPs) in appropriate treatment selection for people with T2DM who are at risk of developing or have established CVD and examines the role of SGLT2i therapy for these people.Funding: Napp Pharmaceuticals Limited.
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Affiliation(s)
- Amar Ali
- Oakenhurst Medical Practice, Blackburn, UK
| | - Steve Bain
- Diabetes Research Unit Cymru, Swansea University, Swansea, UK
| | | | | | - Dipesh C Patel
- Department of Diabetes and Endocrinology, Division of Medicine, University College London, London, UK
| | - Marc Evans
- Department of Diabetes, University Hospital Llandough, Llandough, UK
| | | | - June James
- University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Nicola Milne
- CODES (Community Diabetes Education and Support), Manchester University NHS Foundation Trust, Manchester, UK
| | - Adie Viljoen
- Department of Metabolic Medicine/Chemical Pathology, Lister Hospital, Stevenage, UK
| | - John Wilding
- Obesity and Endocrinology Research, University of Liverpool, Liverpool, UK.
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17
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The challenge of heart failure diagnosis and management in primary care in elderly population: Mere illusion or concrete opportunity? Int J Cardiol 2019; 274:248-249. [PMID: 30449330 DOI: 10.1016/j.ijcard.2018.04.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2017] [Revised: 03/06/2018] [Accepted: 04/05/2018] [Indexed: 11/23/2022]
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18
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Smeets M, De Witte P, Peters S, Aertgeerts B, Janssens S, Vaes B. Think-aloud study about the diagnosis of chronic heart failure in Belgian general practice. BMJ Open 2019; 9:e025922. [PMID: 30898828 PMCID: PMC6475198 DOI: 10.1136/bmjopen-2018-025922] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Revised: 11/17/2018] [Accepted: 02/06/2019] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVES Diagnosing chronic heart failure (CHF) in general practice is challenging. Our aim was to investigate how general practitioners (GPs) diagnose CHF in real-world patients. DESIGN Think-aloud study. METHODS Fourteen GPs were asked to reason about four real-world CHF cases from their own practices. The cases were selected through a clinical audit. This was followed by an interview to get a deeper insight in their reasoning. The Qualitative Analysis Guide of Leuven was used as a guide in data analysis. RESULTS We developed a conceptual diagnostic model based on three important reasoning steps. First, GPs assessed the likelihood of CHF based on the presence or absence of HF signs and symptoms. However, this approach had serious limitations since GPs experienced many barriers in their clinical assessment, especially in comorbid elderly. Second, if CHF was considered based on step 1, the main influencing factor to take further diagnostic steps was the GPs' perception of the added value of a validated CHF diagnosis in that specific case. Third, the choice and implications of these further diagnostic steps (N-terminal pro B-type natriuretic peptide, ECG and/or cardiac ultrasound) were influenced by the GPs' knowledge about these tests and the quality of the cardiologists' reports. CONCLUSION This think-aloud study identified the factors that influenced the diagnostic reasoning about CHF in general practice. As a consequence, targets to improve this diagnostic reasoning were withheld: a paradigm shift towards an earlier and more comprehensive risk assessment with, among others, access to natriuretic peptide testing and convincing GPs of the added value of a validated HF diagnosis.
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Affiliation(s)
- Miek Smeets
- Department of Public Health and Primary Care, Katholieke Universiteit Leuven Groep Biomedische Wetenschappen, Leuven, Belgium
| | - Pieter De Witte
- Department of Public Health and Primary Care, Katholieke Universiteit Leuven Groep Biomedische Wetenschappen, Leuven, Belgium
| | - Sanne Peters
- Department of Public Health and Primary Care, Katholieke Universiteit Leuven Groep Biomedische Wetenschappen, Leuven, Belgium
| | - Bert Aertgeerts
- Department of Public Health and Primary Care, Katholieke Universiteit Leuven Groep Biomedische Wetenschappen, Leuven, Belgium
| | - Stefan Janssens
- Department of Cardiovascular Diseases, Universitair Ziekenhuis Leuven Context, Leuven, Belgium
| | - Bert Vaes
- Department of Public Health and Primary Care, Katholieke Universiteit Leuven Groep Biomedische Wetenschappen, Leuven, Belgium
- Institute of Health and Society, Université Catholique de Louvain (UCL), Brussels, Belgium
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19
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White RD, Kirsch J, Bolen MA, Batlle JC, Brown RK, Eberhardt RT, Hurwitz LM, Inacio JR, Jin JO, Krishnamurthy R, Leipsic JA, Rajiah P, Shah AB, Singh SP, Villines TC, Zimmerman SL, Abbara S. ACR Appropriateness Criteria® Suspected New-Onset and Known Nonacute Heart Failure. J Am Coll Radiol 2018; 15:S418-S431. [DOI: 10.1016/j.jacr.2018.09.031] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Accepted: 09/07/2018] [Indexed: 12/21/2022]
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20
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Verhees RAF, Dondorp W, Thijs C, Dinant GJ, Knottnerus JA. Influenza vaccination in the elderly: Is a trial on mortality ethically acceptable? Vaccine 2018; 36:2991-2997. [PMID: 29691101 DOI: 10.1016/j.vaccine.2018.04.027] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Revised: 04/10/2018] [Accepted: 04/11/2018] [Indexed: 11/24/2022]
Abstract
The effectiveness of influenza vaccination in the elderly has long been a topic of debate, fueled by the absence of direct evidence from randomized trials on its effect on mortality and the methodological limitations of observational studies pointing this direction. It is argued that new placebo-controlled trials should be undertaken to resolve this uncertainty. However, such trials may be ethically questionable. To bring this discussion forward, we provide a comprehensive overview of the ethical challenges of an influenza vaccine efficacy trial designed to evaluate mortality in the elderly. An important condition in the justification of a trial is the existence of genuine uncertainty in regard to the answer to a research question. Therefore an extensive analysis of the existing levels of knowledge is needed to support the conclusion that an effect of vaccination on mortality is uncertain. Even if a so called "clinical equipoise" status applies, denying a control group vaccination would be problematic because vaccination is considered "competent care" and withholding vaccination could substantially increase patients' risk for influenza and its complications. Given the high burden of disease and already proven benefits of vaccination, such a trial is unlikely to meet the Declaration of Helsinki stating that the importance of a trial must outweigh the risk patients are exposed to. While a placebo-controlled trial in vaccine refusers may be considered, such a trial is unlikely to meet substantial methodological barriers regarding trial size and generalizability. We conclude that a new trial is unlikely to provide for a direct answer, let alone change current policy. At the same time, given the lack of consensus on the ethical acceptability of a placebo-controlled trial on the effect of influenza vaccination on mortality in the elderly, we invite researchers considering such trials to address the ethical challenges discussed in this manuscript.
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Affiliation(s)
- Ruud Andreas Fritz Verhees
- Department of Family Medicine, School for Public Health and Primary Care (CAPHRI), Maastricht University, P.O. Box 616, 6200 MD Maastricht, The Netherlands.
| | - Wybo Dondorp
- Department of Health, Ethics and Society, School for Public Health and Primary Care (CAPHRI), Maastricht University, P.O. Box 616, 6200 MD Maastricht, The Netherlands
| | - Carel Thijs
- Department of Epidemiology, School for Public Health and Primary Care (CAPHRI), Maastricht University, P.O. Box 616, 6200 MD Maastricht, The Netherlands
| | - Geert Jan Dinant
- Department of Family Medicine, School for Public Health and Primary Care (CAPHRI), Maastricht University, P.O. Box 616, 6200 MD Maastricht, The Netherlands
| | - Johannes Andreas Knottnerus
- Department of Family Medicine, School for Public Health and Primary Care (CAPHRI), Maastricht University, P.O. Box 616, 6200 MD Maastricht, The Netherlands
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Heckman GA, Shamji AK, Ladha R, Stapleton J, Boscart V, Boxer RS, Martin LB, Crutchlow L, McKelvie RS. Heart Failure Management in Nursing Homes: A Scoping Literature Review. Can J Cardiol 2018; 34:871-880. [DOI: 10.1016/j.cjca.2018.04.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2018] [Revised: 03/31/2018] [Accepted: 04/08/2018] [Indexed: 10/17/2022] Open
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22
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Smeets M, Henrard S, Aertgeerts B, Cools F, Janssens S, Vaes B. Methods to identify heart failure patients in general practice and their impact on patient characteristics: A systematic review. Int J Cardiol 2018; 257:199-206. [PMID: 29395362 DOI: 10.1016/j.ijcard.2017.06.108] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2017] [Revised: 06/07/2017] [Accepted: 06/27/2017] [Indexed: 12/16/2022]
Abstract
BACKGROUND Identifying patients with heart failure (HF) in general practice is challenging. Our aim was to provide an overview of methods used to identify patients with HF in general practice and to assess their impact on patient characteristics. METHODS AND RESULTS A systematic review was conducted using MEDLINE, EMBASE and CENTRAL. Taken together, 105 studies on HF in general practice were included, totalling 196,105 patients. Five main identification methods for HF were distinguished, including 1) echocardiographic assessments, 2) results of echocardiography in general practitioner (GP) charts, 3) GP judgment after chart review, 4) GP judgment of consecutive patients and 5) only chart review. Only 30% of studies used the results of echocardiography. Despite a large heterogeneity between studies the pooled data revealed a predominant phenotype of older women with hypertension rather than ischaemic heart disease. Linear regression analysis showed that the impact of the identification method on patient characteristics was limited. However, study design had a greater impact, with randomized-controlled trials (RCTs) including younger, male patients with ischaemic heart disease and higher HF drug prescription rates at baseline. CONCLUSION Pooled data of 196,105 patients with HF confirmed a phenotype of older women with hypertension rather than ischaemic heart disease as the predominant HF population in general practice. The lack of a gold standard definition of HF introduced a large heterogeneity in identification methods with remarkably limited impact on patient characteristics. However, RCTs did include patients with a different phenotype, emphasizing the need to promote inclusion of real-world HF patients.
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Affiliation(s)
- Miek Smeets
- Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium.
| | - Séverine Henrard
- Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium; Institute of Health and Society, Université Catholique de Louvain, Brussel, Belgium
| | - Bert Aertgeerts
- Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium; CEBAM, Centre for Evidence Based Medicine, Belgium Cochrane Centre, Belgium
| | - Filip Cools
- CEBAM, Centre for Evidence Based Medicine, Belgium Cochrane Centre, Belgium; Department of Neonatology, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussel, Belgium
| | - Stefan Janssens
- Department of Cardiovascular Diseases, Universitair Ziekenhuis Gasthuisberg, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Bert Vaes
- Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium; Institute of Health and Society, Université Catholique de Louvain, Brussel, Belgium
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23
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Bahrmann P, Hardt R. [Chronic heart failure in older patients : Updated national healthcare guidelines on chronic heart failure from a geriatric perspective]. Z Gerontol Geriatr 2018; 51:165-168. [PMID: 29374297 DOI: 10.1007/s00391-018-1371-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Revised: 12/05/2017] [Accepted: 01/08/2018] [Indexed: 12/28/2022]
Abstract
The incidence and prevalence of chronic heart failure (CHF) increase with age. In the second edition of the National Disease Management Guidelines (NVL) on CHF, published in August 2017, geriatric aspects are specifically addressed. The paper provides an overview of the recommendations by the guidelines on drug therapy, device therapy and operative therapy as well on the coordination of care focusing on older and multimorbid patients.
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Affiliation(s)
- Philipp Bahrmann
- Institut für Biomedizin des Alterns (IBA), Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Deutschland. .,Med. Klinik II, Asklepios Paulinen Klinik Wiesbaden, Geisenheimer Str. 10, 65197, Wiesbaden, Deutschland.
| | - Roland Hardt
- Universitätsmedizin der Johannes Gutenberg-Universität Mainz, Mainz, Deutschland
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Kubala M, Guédon-Moreau L, Anselme F, Klug D, Bertaina G, Traullé S, Buiciuc O, Savouré A, Diouf M, Hermida JS. Utility of Frailty Assessment for Elderly Patients Undergoing Cardiac Resynchronization Therapy. JACC Clin Electrophysiol 2017; 3:1523-1533. [DOI: 10.1016/j.jacep.2017.06.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Revised: 06/14/2017] [Accepted: 06/30/2017] [Indexed: 01/24/2023]
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Wizner B, Fedyk-Łukasik M, Opolski G, Zdrojewski T, Windak A, Czech M, Dubiel JS, Marchel M, Rewiuk K, Rywik T, Korewicki J, Grodzicki T. Chronic heart failure management in primary healthcare in Poland: Results of a nationwide cross-sectional study. Eur J Gen Pract 2017; 24:1-8. [PMID: 29164946 PMCID: PMC5774260 DOI: 10.1080/13814788.2017.1368490] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Background: Organizational and educational activities in primary care in Poland have been introduced to improve the chronic heart failure (CHF) management. Objectives: To assess the use of diagnostic procedures, pharmacotherapy and referrals of CHF in primary care in Poland. Methods: The cross-sectional survey was conducted in 2013, involving 390 primary care centres randomly selected from a national database. Trained nurses contacted primary care physicians who retrospectively filled out the study questionnaires on the previous year’s CHF management in the last five patients who had recently visited their office. The data on diagnostic and treatment procedures were collected. Results: The mean age ± SD of the 2006 patients was 72 ± 11 years, 45% were female, and 56% had left ventricular ejection fraction <50%. The percentage of the CHF patients diagnosed based on echocardiography was 67% and significantly increased during the last decade. Echocardiography was still less frequently performed in older patients (≥80 years) than in the younger ones (respectively 50% versus 72%, Ρ <0.001) and in women than in men (62% versus 71%, P <0.001). The percentage of the patients treated with β-blocker alone was 88%, but those with a combination of angiotensin inhibition 71%. The decade before, these percentages were 68% and 57%, respectively. Moreover, an age-related gap observed in the use of the above-mentioned therapy has disappeared. Conclusion: The use of echocardiography in CHF diagnostics has significantly improved in primary care in Poland but a noticeable inequality in the geriatric patients and women remains. Most CHF patients received drug classes in accordance with guidelines.
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Affiliation(s)
- Barbara Wizner
- a Department of Internal Medicine and Gerontology , Jagiellonian University Medical College , Krakow , Poland
| | - Małgorzata Fedyk-Łukasik
- a Department of Internal Medicine and Gerontology , Jagiellonian University Medical College , Krakow , Poland
| | - Grzegorz Opolski
- b Department of Cardiology , Medical University of Warsaw , Warsaw , Poland
| | - Tomasz Zdrojewski
- c Department of Preventive Medicine and Education , Medical University of Gdansk , Gdansk , Poland
| | - Adam Windak
- d Department of Family Medicine , Jagiellonian University Medical College , Krakow , Poland
| | - Marcin Czech
- e Department of Pharmacoeconomics , Medical University of Warsaw , Warsaw , Poland.,f Business School , Warsaw University of Technology , Warsaw , Poland
| | - Jacek S Dubiel
- g Department of Cardiology , Jagiellonian University Medical College and University Hospital , Krakow , Poland
| | - Michał Marchel
- b Department of Cardiology , Medical University of Warsaw , Warsaw , Poland
| | - Krzysztof Rewiuk
- a Department of Internal Medicine and Gerontology , Jagiellonian University Medical College , Krakow , Poland
| | - Tomasz Rywik
- h Department of Heart Failure and Transplantology , Institute of Cardiology , Warsaw , Poland
| | - Jerzy Korewicki
- h Department of Heart Failure and Transplantology , Institute of Cardiology , Warsaw , Poland
| | - Tomasz Grodzicki
- a Department of Internal Medicine and Gerontology , Jagiellonian University Medical College , Krakow , Poland
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Levitan EB, Van Dyke MK, Chen L, Durant RW, Brown TM, Rhodes JD, Olubowale O, Adegbala OM, Kilgore ML, Blackburn J, Albright KC, Safford MM. Medical therapy following hospitalization for heart failure with reduced ejection fraction and association with discharge to long-term care: a cross-sectional analysis of the REasons for Geographic And Racial Differences in Stroke (REGARDS) population. BMC Cardiovasc Disord 2017; 17:249. [PMID: 28915854 PMCID: PMC5602915 DOI: 10.1186/s12872-017-0682-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Accepted: 09/11/2017] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Less intensive treatment for heart failure with reduced ejection fraction (HFrEF) may be appropriate for patients in long-term care settings because of limited life expectancy, frailty, comorbidities, and emphasis on quality of life. METHODS We compared treatment patterns between REasons for Geographic And Racial Differences in Stroke (REGARDS) study participants discharged to long-term care versus home following HFrEF hospitalizations. We examined medical records and Medicare pharmacy claims for 147 HFrEF hospitalizations among 80 participants to obtain information about discharge disposition and medication prescriptions and fills. RESULTS Discharge to long-term care followed 22 of 147 HFrEF hospitalizations (15%). Participants discharged to long-term care were more likely to be prescribed beta-blockers and less likely to be prescribed aldosterone receptor antagonists and hydralazine/isosorbide dinitrate (96%, 14%, and 5%, respectively) compared to participants discharged home (81%, 22%, and 23%, respectively). The percentages of participants discharged to long-term care and home who had claims for filled prescriptions were similar for beta-blockers (68% versus 66%) and angiotensin converting enzyme inhibitors or angiotensin receptor blockers (ACEI/ARBs) (45% versus 47%) after 1 year. Smaller percentages of participants discharged to long-term care had claims for filled prescriptions of other medications compared to participants discharged home (diuretics: long-term care-50%, home-72%; hydralazine/isosorbide dinitrate: long-term care-5%, home-23%; aldosterone receptor antagonists: long-term care-5%, home-23%). CONCLUSIONS Differences in medication prescriptions and fills among individuals with HFrEF discharged to long-term care versus home may reflect prioritization of some medical therapies over others for patients in long-term care.
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Affiliation(s)
- Emily B Levitan
- University of Alabama at Birmingham, Birmingham, AL, USA.
- Department of Epidemiology, University of Alabama at Birmingham, 1720 2nd Ave S, RPHB 220, Birmingham, AL, 35294-0022, USA.
| | | | - Ligong Chen
- University of Alabama at Birmingham, Birmingham, AL, USA
| | | | - Todd M Brown
- University of Alabama at Birmingham, Birmingham, AL, USA
| | - J David Rhodes
- University of Alabama at Birmingham, Birmingham, AL, USA
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Heckman GA, Boscart VM, Huson K, Costa A, Harkness K, Hirdes JP, Stolee P, McKelvie RS. Enhancing Knowledge and InterProfessional care for Heart Failure (EKWIP-HF) in long-term care: a pilot study. Pilot Feasibility Stud 2017; 4:9. [PMID: 28694988 PMCID: PMC5501130 DOI: 10.1186/s40814-017-0153-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Accepted: 06/08/2017] [Indexed: 12/05/2022] Open
Abstract
Background Heart failure (HF) affects 20% of long-term care (LTC) residents and is associated with significant morbidity, acute care visits, and mortality. Barriers to HF management are staff knowledge gaps and ineffective interprofessional (IP) communication. This pilot study assessed the acceptability, feasibility, and impact of an intervention to (1) improve HF knowledge; (2) improve IP communication; and (3) integrate improved knowledge and communication processes into work routines. Methods The intervention provides multimodal IP education about HF in LTC, including specialist-supported bedside teaching. It was piloted on single units in two facilities. A mixed-methods repeated-measures approach was used to collect qualitative and quantitative process and outcome data at baseline and 6 months post-intervention. Results Results were similar at both sites. Participants developed optimized IP communication to promote HF care. Results indicate a perceived increase in staff confidence and self-efficacy, strengthened assessment and clinical proficiency skills, and more effective IP collaboration. Staff deemed the intervention useful and feasible. Conclusions This pilot study suggests that a novel intervention in which HF-specific knowledge is applied by LTC staff to improve IP collaboration in their own work place is acceptable and feasible and has a favourable preliminary impact on staff knowledge and IP communication.
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Affiliation(s)
- George A Heckman
- Research Institute for Aging, 250 Laurelwood Drive, Waterloo, Ontario N2J 0E2 Canada.,School of Public Health and Health Systems, University of Waterloo, 200 University Avenue West, Waterloo, Ontario N2L 3G1 Canada
| | - Veronique M Boscart
- Research Institute for Aging, 250 Laurelwood Drive, Waterloo, Ontario N2J 0E2 Canada.,School of Health & Life Sciences and Community Services, Conestoga College Institute of Technology and Advanced Learning, 299 Doon Valley Dr, Kitchener, Ontario N2G 4M4 Canada
| | - Kelsey Huson
- School of Health & Life Sciences and Community Services, Conestoga College Institute of Technology and Advanced Learning, 299 Doon Valley Dr, Kitchener, Ontario N2G 4M4 Canada
| | - Andrew Costa
- Research Institute for Aging, 250 Laurelwood Drive, Waterloo, Ontario N2J 0E2 Canada.,Department of Clinical Epidemiology and Biostatistics and Medicine, McMaster University, 1280 Main St W, Hamilton, Ontario L8S 4L8 Canada
| | - Karen Harkness
- Heart Failure and Cardiovascular Chronic Disease Management, Cardiac Care Network, 4100 Yonge St, North York, Ontario M2P 2B5 Canada.,Hamilton Health Sciences Corporation, 1200 Main St. West, Hamilton, Ontario L8N 3Z5 Canada.,McMaster University, 1280 Main St W, Hamilton, Ontario L8S 4L8 Canada
| | - John P Hirdes
- School of Public Health and Health Systems, University of Waterloo, 200 University Avenue West, Waterloo, Ontario N2L 3G1 Canada
| | - Paul Stolee
- School of Public Health and Health Systems, University of Waterloo, 200 University Avenue West, Waterloo, Ontario N2L 3G1 Canada
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28
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Aissat-Bessalem O, François Fasille V. [Heart failure and nursing homes]. SOINS. GERONTOLOGIE 2017; 22:12-15. [PMID: 28687127 DOI: 10.1016/j.sger.2017.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Heart failure is a very common condition in elderly people, particularly those living away from home, in institutional care. The main objective of a study was to find out whether patients with heart failure admitted to a nursing home benefit or not from the same ultrasound assessment as the general population. The secondary objective was to analyse the management of residents with heart failure living in institutional care.
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29
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Cuthbert JJ, Pellicori P, Clark AL. Interatrial shunt devices for heart failure with normal ejection fraction: a technology update. MEDICAL DEVICES-EVIDENCE AND RESEARCH 2017; 10:123-132. [PMID: 28652826 PMCID: PMC5476655 DOI: 10.2147/mder.s113105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Heart failure with normal ejection fraction (HeFNEF) accounts for ~50% of heart failure admissions. Its pathophysiology and diagnostic criteria are yet to be defined clearly which may hinder the search for effective treatments. The clinical hallmark of HeFNEF is exertional breathlessness, often due to an abnormal increase in left atrial pressure during exercise. Creation of an interatrial communication to offload the left atrium is a possible therapeutic approach. There are two percutaneously delivered devices currently under investigation which are discussed in this review.
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Affiliation(s)
- Joseph J Cuthbert
- Department of Cardiology, Hull York Medical School, Hull and East Yorkshire Medical Research and Teaching Centre, Castle Hill Hospital, Cottingham, Kingston upon Hull, UK
| | - Pierpaolo Pellicori
- Department of Cardiology, Hull York Medical School, Hull and East Yorkshire Medical Research and Teaching Centre, Castle Hill Hospital, Cottingham, Kingston upon Hull, UK
| | - Andrew L Clark
- Department of Cardiology, Hull York Medical School, Hull and East Yorkshire Medical Research and Teaching Centre, Castle Hill Hospital, Cottingham, Kingston upon Hull, UK
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30
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Atramont A, Rigault A, Chevalier S, Leblanc G, Fagot-Campagna A, Tuppin P. Caractéristiques, pathologies et mortalité des résidents en établissements d’hébergement pour personnes âgées dépendantes (Ehpad) admis au cours du premier trimestre 2013 en France. Rev Epidemiol Sante Publique 2017; 65:221-230. [DOI: 10.1016/j.respe.2016.11.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Accepted: 11/21/2016] [Indexed: 02/08/2023] Open
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Hill E, Taylor J. Chronic Heart Failure Care Planning: Considerations in Older Patients. Card Fail Rev 2017; 3:46-51. [PMID: 28785475 PMCID: PMC5494157 DOI: 10.15420/cfr.2016:15:2] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Accepted: 10/18/2016] [Indexed: 01/27/2023] Open
Abstract
In developed countries, it is estimated that more than 10 % of adults aged over 70 years have heart failure (HF). Despite therapeutic advances, it remains a condition associated with significant morbidity and mortality. It is one of the commonest causes of unscheduled hospital admissions in older adults and data consistently show a lower uptake of evidence-based investigations and therapies as well as higher rates of HF hospitalisations and mortality than in younger adults. These rates are highest amongst patients discharged to 'skilled nursing facilities', where comorbidities, frailty and cognitive impairment are common and have a significant impact on outcomes. In this review, we examine current guidance and its limitations and offer a pragmatic approach to management of HF in this elderly population.
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Affiliation(s)
- Eilidh Hill
- Department of Geriatric Medicine, Glasgow Royal Infirmary, Glasgow, UK
| | - Jackie Taylor
- Department of Geriatric Medicine, Glasgow Royal Infirmary, Glasgow, UK
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32
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Daamen M, Brunner-la Rocca HP, Tan F, Hamers J, Schols J. Clinical diagnosis of heart failure in nursing home residents based on history, physical exam, BNP and ECG: Is it reliable? Eur Geriatr Med 2017. [DOI: 10.1016/j.eurger.2016.10.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Decaluwe K, Degryse J, Vaes B. Evaluating the scripts and thresholds of general practitioners for diagnosing heart failure in elderly people. BMC FAMILY PRACTICE 2016; 17:86. [PMID: 27439700 PMCID: PMC4955166 DOI: 10.1186/s12875-016-0481-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/12/2015] [Accepted: 07/13/2016] [Indexed: 11/10/2022]
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Smeets M, Degryse J, Janssens S, Matheï C, Wallemacq P, Vanoverschelde JL, Aertgeerts B, Vaes B. Diagnostic rules and algorithms for the diagnosis of non-acute heart failure in patients 80 years of age and older: a diagnostic accuracy and validation study. BMJ Open 2016; 6:e012888. [PMID: 27855108 PMCID: PMC5073666 DOI: 10.1136/bmjopen-2016-012888] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
OBJECTIVES Different diagnostic algorithms for non-acute heart failure (HF) exist. Our aim was to compare the ability of these algorithms to identify HF in symptomatic patients aged 80 years and older and identify those patients at highest risk for mortality. DESIGN Diagnostic accuracy and validation study. SETTING General practice, Belgium. PARTICIPANTS 365 patients with HF symptoms aged 80 years and older (BELFRAIL cohort). Participants underwent a full clinical assessment, including a detailed echocardiographic examination at home. OUTCOME MEASURES The diagnostic accuracy of 4 different algorithms was compared using an intention-to-diagnose analysis. The European Society of Cardiology (ESC) definition of HF was used as the reference standard for HF diagnosis. Kaplan-Meier curves for 5-year all-cause mortality were plotted and HRs and corresponding 95% CIs were calculated to compare the mortality risk predicting abilities of the different algorithms. Net reclassification improvement (NRI) was calculated. RESULTS The prevalence of HF was 20% (n=74). The 2012 ESC algorithm yielded the highest sensitivity (92%, 95% CI 83% to 97%) as well as the highest referral rate (71%, n=259), whereas the Oudejans algorithm yielded the highest specificity (73%, 95% CI 68% to 78%) and the lowest referral rate (36%, n=133). These differences could be ascribed to differences in N-terminal probrain natriuretic peptide cut-off values (125 vs 400 pg/mL). The Kelder and Oudejans algorithms exhibited NRIs of 12% (95% CI 0.7% to 22%, p=0.04) and 22% (95% CI 9% to 32%, p<0.001), respectively, compared with the ESC algorithm. All algorithms detected patients at high risk for mortality (HR 1.9, 95% CI 1.4 to 2.5; Kelder) to 2.3 (95% CI 1.7 to 3.1; Oudejans). No significant differences were observed among the algorithms with respect to mortality risk predicting abilities. CONCLUSIONS Choosing a diagnostic algorithm for non-acute HF in elderly patients represents a trade-off between sensitivity and specificity, mainly depending on differences between cut-off values for natriuretic peptides.
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Affiliation(s)
- Miek Smeets
- Department of Public Health and Primary Care, KU Leuven (KUL), Leuven, Belgium
| | - Jan Degryse
- Department of Public Health and Primary Care, KU Leuven (KUL), Leuven, Belgium
- Institute of Health and Society, Université Catholique de Louvain (UCL), Brussels, Belgium
| | - Stefan Janssens
- Department of Cardiovascular Diseases, Universitair Ziekenhuis Gasthuisberg, KU Leuven (KUL), Leuven, Belgium
| | - Catharina Matheï
- Department of Public Health and Primary Care, KU Leuven (KUL), Leuven, Belgium
| | - Pierre Wallemacq
- Laboratory of Analytical Biochemistry, Cliniques Universitaires St Luc, Université Catholique de Louvain (UCL), Brussels, Belgium
| | - Jean-Louis Vanoverschelde
- Department of Cardiology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain (UCL), Brussels, Belgium
| | - Bert Aertgeerts
- Department of Public Health and Primary Care, KU Leuven (KUL), Leuven, Belgium
| | - Bert Vaes
- Department of Public Health and Primary Care, KU Leuven (KUL), Leuven, Belgium
- Institute of Health and Society, Université Catholique de Louvain (UCL), Brussels, Belgium
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Huis In 't Veld AE, de Man FS, van Rossum AC, Handoko ML. How to diagnose heart failure with preserved ejection fraction: the value of invasive stress testing. Neth Heart J 2016; 24:244-51. [PMID: 26914917 PMCID: PMC4796056 DOI: 10.1007/s12471-016-0811-0] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Heart failure with preserved ejection fraction (HFpEF) is a growing healthcare burden worldwide and its prevalence is increasing. Diagnosing HFpEF is challenging and relies upon the presence of symptoms and/or signs of heart failure, preserved left ventricular systolic function, and evidence of diastolic dysfunction. Current diagnostic algorithms mainly rely on echocardiography (E/e’) and biomarkers (NT-proBNP). However, only a minority of patients with HFpEF are identified, and especially HFpEF patients at an early stage of the disease are easily missed. We propose to incorporate invasive stress testing, by means of right heart catheterisation at rest and during exercise, and accurate assessment of right ventricular function, by means of cardiac magnetic resonance imaging. These additions to the current diagnostic work-up will improve diagnostic sensitivity and accurate staging of HFpEF patients.
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Affiliation(s)
- A E Huis In 't Veld
- Department of Pulmonology, Institute for Cardiovascular Research (ICaR-VU), VU University Medical Centre (VUmc), Amsterdam, The Netherlands
| | - F S de Man
- Department of Pulmonology, Institute for Cardiovascular Research (ICaR-VU), VU University Medical Centre (VUmc), Amsterdam, The Netherlands
| | - A C van Rossum
- Department of Cardiology, ICaR-VU, VUmc, Amsterdam, The Netherlands
| | - M L Handoko
- Department of Cardiology, ICaR-VU, VUmc, Amsterdam, The Netherlands.
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Abstract
Background For the treatment of chronic heart failure (HF), both pharmacological and non-pharmacological treatment should be employed in HF patients. Although HF is highly prevalent in nursing home residents, it is not clear whether the recommendations in the guidelines for pharmacological therapy also are followed in nursing home residents. The aim of this study is to investigate how HF is treated in nursing home residents and to determine to what extent the current treatment corresponds to the guidelines. Methods Nursing home residents of five large nursing home care organizations in the southern part of the Netherlands with a previous diagnosis of HF based on medical records irrespective of the left ventricle ejection fraction (LVEF) were included in this cross-sectional design study. Data were gathered on the (medical) records, which included clinical characteristics and pharmacological- and non-pharmacological treatment. Echocardiography was used as part of the study to determine the LVEF. Results Out of 501 residents, 112 had a diagnosis of HF at inclusion. One-third of them received an ACE-inhibitor and 40% used a β-blocker. In 66%, there was a prescription of diuretics with a preference of a loop diuretic. Focusing on the residents with a LVEF ≤ 40%, only 46% of the 22 residents used an ACE-inhibitor and 64% a β-blocker. The median daily doses of prescribed medication were lower than those that were recommended by the guidelines. Non-pharmacological interventions were recorded in almost none of the residents with HF. Conclusions The recommended medical therapy of HF was often not prescribed; if prescribed, the dosage was usually far below what was recommended. In addition, non-pharmacological interventions were mostly not used at all.
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Selan S, Siennicki-Lantz A, Berglund J, Fagerström C. Self-awareness of heart failure in the oldest old-an observational study of participants, ≥ 80 years old, with an objectively verified heart failure. BMC Geriatr 2016; 16:23. [PMID: 26791263 PMCID: PMC4721017 DOI: 10.1186/s12877-016-0195-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2015] [Accepted: 01/12/2016] [Indexed: 11/25/2022] Open
Abstract
Background One of the primary reasons for hospitalisation among elderly individuals with heart failure (HF) is poor self-care. Self-awareness of having HF may be a key-element in successful self-care. The prevalence of self-awareness of HF, and how it is affected by age-and HF-related factors, remains poorly understood. The aims of the present study were to determine the prevalence of self-awareness of HF in participants, ≥ 80 years of age, and to investigate the association between this self-awareness and age-related and HF-related factors. Methods A single-centre observational study was conducted in which non-hospitalised participants (80+) with objectively verified HF were identified (n = 90). The statement of having HF or not having HF was used to divide the participants into two groups for comparisons: aware or unaware of one’s own HF. Logistic regression models were completed to determine the impact of age-and HF-related factors on self-awareness. Results Twenty-six percent (23/90) were aware of their own HF diagnosis. No significant differences were found between the participants who were aware of their own HF diagnosis and the participants who were not. Neither age-nor HF-related factors had influence on the prevalence of self-awareness. Conclusions Prevalence of self-awareness of own HF in the oldest old is insufficient, and this self-awareness may be influenced by external factors. One such factor is likely the manner in which the HF diagnosis is relayed to the patient by health care professionals.
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Affiliation(s)
- Suzana Selan
- Department of Health, Blekinge Institute of Technology, Karlskrona, Sweden. .,Department of Health Sciences, Faculty of Medicine, Lund University, Lund, Sweden.
| | - Arkadiusz Siennicki-Lantz
- Division of Geriatric Medicine, Department of Health Sciences, Malmö University Hospital, Malmö, Sweden
| | - Johan Berglund
- Department of Health, Blekinge Institute of Technology, Karlskrona, Sweden.,Blekinge Centre of Competence, SE-371 81, Karlskrona, Sweden
| | - Cecilia Fagerström
- Department of Health, Blekinge Institute of Technology, Karlskrona, Sweden.,Blekinge Centre of Competence, SE-371 81, Karlskrona, Sweden
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Jurgens CY, Goodlin S, Dolansky M, Ahmed A, Fonarow GC, Boxer R, Arena R, Blank L, Buck HG, Cranmer K, Fleg JL, Lampert RJ, Lennie TA, Lindenfeld J, Piña IL, Semla TP, Trebbien P, Rich MW. Heart failure management in skilled nursing facilities: a scientific statement from the American Heart Association and the Heart Failure Society of America. J Card Fail 2016; 21:263-99. [PMID: 25863664 DOI: 10.1016/j.cardfail.2015.02.007] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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Daamen MAMJ, Hamers JPH, Gorgels APM, Brunner-La Rocca HP, Tan FES, van Dieijen-Visser MP, Schols JMGA. Heart failure in nursing home residents; a cross-sectional study to determine the prevalence and clinical characteristics. BMC Geriatr 2015; 15:167. [PMID: 26675117 PMCID: PMC4681153 DOI: 10.1186/s12877-015-0166-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2015] [Accepted: 12/08/2015] [Indexed: 01/21/2023] Open
Abstract
Background Heart failure (HF) is expected to be highly prevalent in nursing home residents, but precise figures are scarce. The aim of this study was to determine the prevalence of HF in nursing home residents and to get insight in the clinical characteristics of residents with HF. Methods The study followed a multi-centre cross-sectional design. Nursing home residents (n = 501) in the southern part of the Netherlands aged over 65 years and receiving long-term somatic or psychogeriatric care were included in the study. The diagnosis of HF and related characteristics were based on data collected from actual clinical examinations (including history, physical examination, ECG, cardiac markers and echocardiography), patient records and questionnaires. A panel of two cardiologists and a geriatrician ultimately judged the data to diagnose HF. Results The overall prevalence of HF in nursing home residents was 33 %, of which 52 % had HF with preserved ejection fraction. The symptoms dyspnoea and oedema and a cardiac history were more common in residents with HF. Diabetes mellitus, chronic obstructive pulmonary disease (COPD) were also more prevalent in those with HF. Residents with HF had a higher score on the Mini Mental State Examination. 54 % of those with HF where not known before, and in 31 % with a history of HF, this diagnosis was not confirmed by the expert panel. Conclusion This study shows that HF is highly prevalent in nursing home residents with many unknown or falsely diagnosed with HF. Equal number of HF patients had reduced and preserved left-ventricular ejection fraction. Trial registration The Netherlands National Trial Register NTR2663 (27-12-2010)
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Affiliation(s)
- Mariëlle A M J Daamen
- Department of Health Services Research, Research School Caphri, Maastricht University, Maastricht, The Netherlands.
| | - Jan P H Hamers
- Department of Health Services Research, Research School Caphri, Maastricht University, Maastricht, The Netherlands.
| | - Anton P M Gorgels
- Department of Cardiology, Maastricht University Medical Centre, Maastricht, The Netherlands.
| | | | - Frans E S Tan
- Department of Methodology and Statistics, Research School Caphri, Maastricht University, Maastricht, The Netherlands.
| | | | - Jos M G A Schols
- Department of Health Services Research, Research School Caphri, Maastricht University, Maastricht, The Netherlands. .,Department of Family Medicine, Research School Caphri, Maastricht University, Maastricht, The Netherlands.
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Hage C, Lund LH, Donal E, Daubert JC, Linde C, Mellbin L. Copeptin in patients with heart failure and preserved ejection fraction: a report from the prospective KaRen-study. Open Heart 2015; 2:e000260. [PMID: 26568833 PMCID: PMC4636678 DOI: 10.1136/openhrt-2015-000260] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2015] [Revised: 09/08/2015] [Accepted: 10/13/2015] [Indexed: 01/08/2023] Open
Abstract
INTRODUCTION Underlying mechanisms of heart failure (HF) with preserved ejection fraction (HFPEF) remain unknown. We explored copeptin, a biomarker of the arginine vasopressin system, hypothesising that copeptin in HFPEF is elevated, associated with diastolic dysfunction and N-terminal pro-brain natriuretic peptide (NT-proBNP) and predictive of HF hospitalisation and mortality. METHODS AND ANALYSIS In a prospective observational substudy of the The Karolinska Rennes (KaRen) 86 patients with symptoms of acute HF and ejection fraction (EF) ≥45% were enrolled. After 4-8 weeks, blood sampling and echocardiography was performed. Plasma-copeptin was analysed in 86 patients and 62 healthy controls. Patients were followed in median 579 days (quartile 1; quartile 3 (Q1;Q3) 276;1178) regarding the composite end point all-cause mortality or HF hospitalisation. ETHICS AND DISSEMINATION The patients with HFPEF had higher copeptin levels, median 13.56 pmol/L (Q1;Q3 8.56;20.55) than controls 5.98 pmol/L (4.15;9.42; p<0.001). Diastolic dysfunction, assessable in 75/86 patients, was present in 45 and absent in 30 patients. Copeptin did not differ regarding diastolic dysfunction and did not correlate with cardiac function but with NT-proBNP (r=0.223; p value=0.040). In univariate Cox regression analysis log copeptin predicted the composite end point (HR 1.56 (95% CI 1.03 to 2.38; p value=0.037)) but not after adjusting for NT-proBNP (HR 1.39 (95% CI 0.91 to 2.12; p value=0.125)). CONCLUSIONS In the present patients with HFPEF, copeptin is elevated, correlates with NT-proBNP but not markers of diastolic dysfunction, and has prognostic implications, however blunted after adjustment for NT-proBNP. The HFPEF pathophysiology may be better reflected by markers of neurohormonal activation than by diastolic dysfunction. TRIAL REGISTRATION NUMBER ClinicalTrials.gov NCT00774709.
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Affiliation(s)
- Camilla Hage
- Department of Cardiology , Karolinska University Hospital , Stockholm , Sweden
| | - Lars H Lund
- Department of Cardiology , Karolinska University Hospital , Stockholm , Sweden
| | - Erwan Donal
- Département de Cardiologie , Centre Hospitalier Universitaire de Rennes , Rennes , France
| | - Jean-Claude Daubert
- Département de Cardiologie , Centre Hospitalier Universitaire de Rennes , Rennes , France
| | - Cecilia Linde
- Department of Cardiology , Karolinska University Hospital , Stockholm , Sweden
| | - Linda Mellbin
- Department of Cardiology , Karolinska University Hospital , Stockholm , Sweden
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Cardinaels EPM, Daamen MAMJ, Bekers O, ten Kate J, Niens M, van Suijlen JDE, van Dieijen-Visser MP, Brunner-La Rocca HP, Schols JMGA, Mingels AMA. Clinical Interpretation of Elevated Concentrations of Cardiac Troponin T, but Not Troponin I, in Nursing Home Residents. J Am Med Dir Assoc 2015; 16:884-91. [PMID: 26255708 DOI: 10.1016/j.jamda.2015.06.026] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2015] [Accepted: 06/29/2015] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Cardiac troponins T (cTnT) and I (cTnI) are the preferred biomarkers to detect myocardial damage. The present study explores the value of measuring cardiac troponins (cTn) in nursing home residents, by investigating its relation to heart failure and 1-year mortality using 1 cTnT and 2 cTnI assays that are widely used in clinical practice. DESIGN All participants underwent extensive clinical examinations and echocardiographic assessment for the diagnosis of heart failure. cTn was measured using high-sensitive (hs)- cTnT (Roche), hs-cTnI (Abbott), and sensitive cTnI (Beckman) assays. The glomerular filtration rate was estimated (eGFR) using serum creatinine and cystatin C concentrations. Data on all-cause mortality were collected at 1-year follow-up. PARTICIPANTS AND SETTING Participants were 495 long-term nursing home residents, older than 65 years, of 5 Dutch nursing home organizations. RESULTS Median (IQR) concentrations were 20.6 (17.8-30.6), 6.8 (4.1-12.5), and 4.0 (2.0-8.0) ng/L for hs-cTnT, hs-cTnI, and cTnI, respectively. In total, 79% had elevated hs-cTnT concentrations, whereas only 9% and 5% of hs-cTnI and cTnI concentrations were elevated. Most important and independent determinants for higher hs-cTnT and hs-cTnI concentrations were heart failure and renal dysfunction. Whereas both heart failure (odds ratio [OR] 3.4) and eGFR lower than 60 mL/min/1.73 m(2) (OR 3.6) were equal contributors to higher hs-cTnT concentrations (all P < .001), hs-cTnI and cTnI were less associated with renal dysfunction (OR of, respectively, 1.9 and 2.1; P < .01) in comparison with heart failure (OR 4.3 and 4.7, respectively, P < .001). Furthermore, residents with higher hs-cTnT or hs-cTnI concentrations (fourth quartile) had respectively 4 versus 2 times more risk of 1-year mortality compared with lower concentrations. CONCLUSION Regardless of their cardiac health, hs-cTnT but not hs-cTnI concentrations were elevated in almost all aged nursing home residents, questioning the use of the current diagnostic cutoff in elderly with high comorbidity. Nonetheless, measuring cardiac troponins, especially hs-cTnT, had a promising role in assessing future risk of mortality.
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Affiliation(s)
- Eline P M Cardinaels
- Department of Clinical Chemistry, Central Diagnostic Laboratory and Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands
| | - Mariëlle A M J Daamen
- School for Public Health and Primary Care (CAPHRI), Maastricht University, Maastricht, The Netherlands
| | - Otto Bekers
- Department of Clinical Chemistry, Central Diagnostic Laboratory and Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands
| | - Joop ten Kate
- Department of Clinical Chemistry and Hematology, Atrium-Orbis Medical Center, Sittard, The Netherlands
| | - Marijke Niens
- Department of Clinical Chemistry and Hematology, Gelre Hospitals, Appledoorn, The Netherlands
| | - Jeroen D E van Suijlen
- Department of Clinical Chemistry and Hematology, Gelre Hospitals, Appledoorn, The Netherlands
| | - Marja P van Dieijen-Visser
- Department of Clinical Chemistry, Central Diagnostic Laboratory and Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands
| | | | - Jos M G A Schols
- School for Public Health and Primary Care (CAPHRI), Maastricht University, Maastricht, The Netherlands
| | - Alma M A Mingels
- Department of Clinical Chemistry, Central Diagnostic Laboratory and Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands.
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Smeets M, Degryse J, Aertgeerts B, Janssens S, Adriaensen W, Matheï C, Van Pottelbergh G, Wallemacq P, Vanoverschelde JL, Vaes B. General practitioners' judgement of chronic heart failure in the oldest old: Insights from the BELFRAIL study. Int J Cardiol 2015; 191:120-7. [DOI: 10.1016/j.ijcard.2015.05.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Accepted: 05/02/2015] [Indexed: 10/23/2022]
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Ferrari R, Böhm M, Cleland JG, Paulus WJ, Pieske B, Rapezzi C, Tavazzi L. Heart failure with preserved ejection fraction: uncertainties and dilemmas. Eur J Heart Fail 2015; 17:665-71. [DOI: 10.1002/ejhf.304] [Citation(s) in RCA: 113] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2015] [Revised: 03/10/2015] [Accepted: 04/24/2015] [Indexed: 12/18/2022] Open
Affiliation(s)
- Roberto Ferrari
- Department of Cardiology and LTTA Centre; University Hospital of Ferrara and Maria Cecilia Hospital, GVM Care & Research, ES Health Science Foundation; Cotignola Italy
| | - Michael Böhm
- Universitätsklinikum des Saarlandes; Klinik für Innere Medizin III; Homburg/Saar Germany
| | - John G.F. Cleland
- National Heart & Lung Institute; Harefield Hospital, Imperial College; London UK
| | | | - Burkert Pieske
- Department of Cardiology, Medical University Graz, and Ludwig-Boltzmann-Institute; Translational HF Research; Graz Austria
| | - Claudio Rapezzi
- Cardiology, Department of Experimental Diagnostic and Specialty Medicine; Alma Mater-University of Bologna; Italy
| | - Luigi Tavazzi
- Maria Cecilia Hospital; GVM Care & Research, ES Health Science Foundation; Cotignola Italy
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Jurgens CY, Goodlin S, Dolansky M, Ahmed A, Fonarow GC, Boxer R, Arena R, Blank L, Buck HG, Cranmer K, Fleg JL, Lampert RJ, Lennie TA, Lindenfeld J, Piña IL, Semla TP, Trebbien P, Rich MW. Heart failure management in skilled nursing facilities: a scientific statement from the American Heart Association and the Heart Failure Society of America. Circ Heart Fail 2015; 8:655-87. [PMID: 25855686 DOI: 10.1161/hhf.0000000000000005] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Allen CJ, Guha K, Sharma R. How to Improve Time to Diagnosis in Acute Heart Failure - Clinical Signs and Chest X-ray. Card Fail Rev 2015; 1:69-74. [PMID: 28785435 DOI: 10.15420/cfr.2015.1.2.69] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Acute heart failure (AHF) is a leading cause of hospitalisation in developed nations with stubbornly poor outcomes in both the short and long term. Furthermore, alongside an ageing population the incidence continues to increase. Contemporary practice guidelines accordingly emphasise the importance of early recognition of heart failure in the acute setting to facilitate the timely instigation of key investigations, appropriate management and access to specialist care; all of which improve outcome. However, the diagnosis of AHF is often challenging, with no gold standard diagnostic test and presenting clinical features that may be non-specific, particularly in the elderly where they may be atypical, or masked by co-morbidity. This short review explores the main clinical signs and radiographic changes in patients with AHF relevant to clinical practice in accordance with the best available evidence.
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Affiliation(s)
| | - Kaushik Guha
- Cardiology Department, Royal Brompton Hospital,London, UK.,National Heart and Lung Institute, Imperial College,London, UK
| | - Rakesh Sharma
- Cardiology Department, Royal Brompton Hospital,London, UK.,National Heart and Lung Institute, Imperial College,London, UK
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Bahrmann P, Bahrmann A, Hofner B, Christ M, Achenbach S, Sieber CC, Bertsch T. Multiple biomarker strategy for improved diagnosis of acute heart failure in older patients presenting to the emergency department. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2014; 4:137-47. [PMID: 25002708 DOI: 10.1177/2048872614541904] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
AIM Biomarkers can help to identity acute heart failure (AHF) as the cause of symptoms in patients presenting to the emergency department (ED). Older patients may prove a diagnostic challenge due to co-morbidities. Therefore we prospectively investigated the diagnostic performance of N-terminal pro-B-type natriuretic peptide (NT-proBNP) alone or in combination with other biomarkers for AHF upon admission at the ED. METHODS 302 non-surgical patients aged ≥ 70 years were consecutively enrolled upon admission to the ED. In addition to NT-proBNP, mid-regional pro-adrenomedullin (MR-proADM), mid-regional pro-atrial natriuretic peptide (MR-proANP), C-terminal pro-endothelin-1 (CT-proET-1) and ultra-sensitive C-terminal pro-vasopressin (Copeptin-us) were measured at admission. Two cardiologists independently adjudicated the final diagnosis of AHF after reviewing all available baseline data excluding the biomarkers. We assessed changes in C-index, integrated discrimination improvement (IDI), and net reclassification improvement (NRI) for the multimarker approach. RESULTS AHF was diagnosed in 120 (40%) patients (age 81±6 years, 64 men, 56 women). Adding MR-ADM to NT-proBNP levels improved C-index (0.84 versus 0.81; p=0.045), and yielded IDI (3.3%; p=0.002), NRI (17%, p<0.001) and continuous NRI (33.3%; p=0.002). Adding CT-proET-1 to NT-proBNP levels improved C index (0.86 versus 0.81, p=0.031), and yielded robust IDI (12.4%; p<0.001), NRI (31.3%, p<0.001) and continuous NRI (69.9%; p<0.001). No other dual or triple biomarker combination showed a significant improvement of both C-index and IDI. CONCLUSION In older patients presenting to the ED, the addition of CT-proET-1 or MR-proADM to NT-proBNP improves diagnostic accuracy of AHF. Both dual biomarker approaches offer significant risk reclassification improvement over NT-proBNP.
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Affiliation(s)
- Philipp Bahrmann
- Institute for Biomedicine of Aging, Friedrich-Alexander-University, Nuremberg, Germany
| | - Anke Bahrmann
- Department of Cardiology, Friedrich-Alexander-University, Erlangen, Germany
| | - Benjamin Hofner
- Department of Medical Informatics, Biometry and Epidemiology, Friedrich-Alexander-University, Erlangen, Germany
| | - Michael Christ
- Department of Emergency and Critical Care Medicine, Paracelsus Medical University, Nuremberg, Germany
| | - Stephan Achenbach
- Department of Cardiology, Friedrich-Alexander-University, Erlangen, Germany
| | | | - Thomas Bertsch
- Institute for Clinical Chemistry, Laboratory Medicine and Transfusion Medicine, Paracelsus Medical University, Nuremberg, Germany
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Hancock HC, Close H, Fuat A, Murphy JJ, Hungin APS, Mason JM. Barriers to accurate diagnosis and effective management of heart failure have not changed in the past 10 years: a qualitative study and national survey. BMJ Open 2014; 4:e003866. [PMID: 24691215 PMCID: PMC3975740 DOI: 10.1136/bmjopen-2013-003866] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVES To explore changes in healthcare professionals' views about the diagnosis and management of heart failure since a study in 2003. DESIGN Focus groups and a national online cross-sectional survey. SETTING AND PARTICIPANTS Focus groups (n=8 with a total of 56 participants) were conducted in the North East of England using a phenomenological framework and purposive sampling, informing a UK online survey (n=514). RESULTS 4 categories were identified as contributing to variations in the diagnosis and management of heart failure. Three previously known categories included: uncertainty about clinical practice, the value of clinical guidelines and tensions between individual and organisational practice. A new category concerned uncertainty about end-of-life care. Survey responses found that confidence varied among professional groups in diagnosing left ventricular systolic dysfunction (LVSD): 95% of cardiologists, 93% of general physicians, 66% of general practitioners (GPs) and 32% of heart failure nurses. For heart failure with preserved ejection fraction (HFpEF), confidence levels were much lower: 58% of cardiologists, 43% of general physicians, 7% of GPs and 6% of heart failure nurses. Only 5-35% of respondents used natriuretic peptides for LVSD or HFpEF. Confidence in interpreting test findings was fundamental to the use of all diagnostic tests. Clinical guidelines were reported to be helpful when diagnosing LVSD by 33% of nurses and 50-56% of other groups, but fell to 5-28% for HFpEF. Some GPs did not routinely initiate diuretics (23%), ACE-inhibitors (22%) or β-blockers (38%) for LVSD for reasons including historical teaching, perceived side effects and burden of monitoring. For end-of-life care, there was no consensus about responsibility for heart failure management. CONCLUSIONS Reported differences in the way heart failure is diagnosed and managed have changed little in the past decade. Variable access to diagnostic tests, modes of care delivery and non-uniform management approaches persist. The current National Health Service (NHS) context may not be conducive to addressing these issues.
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Affiliation(s)
- Helen C Hancock
- Durham Clinical Trials Unit, School of Medicine, Pharmacy and Health, Durham University, Queen's Campus, Wolfson Research Institute, Stockton-on-Tees, UK
| | - Helen Close
- Durham Clinical Trials Unit, School of Medicine, Pharmacy and Health, Durham University, Queen's Campus, Wolfson Research Institute, Stockton-on-Tees, UK
| | - Ahmet Fuat
- School of Medicine, Pharmacy and Health, Durham University, Queen's Campus, Wolfson Research Institute, Stockton-on-Tees, UK
- County Durham and Darlington NHS Foundation Trust (CDDFT), Darlington Memorial Hospital, Darlington, County Durham, UK
| | - Jerry J Murphy
- School of Medicine, Pharmacy and Health, Durham University, Queen's Campus, Wolfson Research Institute, Stockton-on-Tees, UK
- County Durham and Darlington NHS Foundation Trust (CDDFT), Darlington Memorial Hospital, Darlington, County Durham, UK
| | - A Pali S Hungin
- School of Medicine, Pharmacy and Health, Durham University, Queen's Campus, Wolfson Research Institute, Stockton-on-Tees, UK
| | - James M Mason
- Durham Clinical Trials Unit, School of Medicine, Pharmacy and Health, Durham University, Queen's Campus, Wolfson Research Institute, Stockton-on-Tees, UK
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Bolmsjö BB, Mölstad S, Östgren CJ, Midlöv P. Prevalence and treatment of heart failure in Swedish nursing homes. BMC Geriatr 2013; 13:118. [PMID: 24188665 PMCID: PMC4228246 DOI: 10.1186/1471-2318-13-118] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2013] [Accepted: 10/28/2013] [Indexed: 12/03/2022] Open
Abstract
Background Since the burden of care for elderly patients with heart failure (HF) can be decreased by therapeutic measures, it is important that such patients are identified correctly. This study explores the prevalence of HF in nursing homes in Sweden, with special consideration of the risk of failure to diagnose HF in the study population. A second aim is to explore medication and the adherence to guidelines for the treatment of HF. Methods 429 patients from 11 nursing homes were included during 2008–2011. Information about diagnoses and medications from patient records, blood samples, questionnaire responses and blood pressure measurements were collected. The baseline characteristics of the patients, their medications and one-year mortality were identified and then compared regarding HF diagnosis and B-type natriuretic peptide (BNP) levels. A BNP level of >100 ng/L was used to identify potential cases of HF. Results The point prevalence of HF diagnosis in the medical records in the study population was 15.4%. With the recommended cut-off value for BNP, up to 196 subjects in the study population (45.7%) qualified for further screening of potential HF. The subjects in the HF and non-HF groups were similar with the exception of mean age, BNP levels and Mini Mental State Examination results which were higher in the HF group, and the eGFR and blood pressure, which were lower when HF. The subjects with higher BNP values were older and had lower eGFR, Hb, diastolic blood pressure and BMI. The subjects with HF diagnoses were in many cases not treated according to the guidelines. Loop diuretics were often used without concomitant ACE inhibitors or angiotensin receptor blockers. The subjects without HF diagnoses in the medical records at inclusion but with BNP values >100 ng/L had less appropriate HF medication. The one-year mortality was 52.9% in the population with HF. Conclusions Our study suggests that the estimated prevalence of HF in nursing homes in Sweden would increase if BNP measurements were used to select patients for further examinations. The pharmacological treatment of HF varied substantially, as did adherence to guidelines.
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Affiliation(s)
- Beata Borgström Bolmsjö
- Department of Clinical Sciences in Malmö, Center for Primary Health Care Research, Lund University, Malmö, Sweden.
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Close H, Hancock H, Mason JM, Murphy JJ, Fuat A, de Belder M, Hungin APS. "It's Somebody else's responsibility" - perceptions of general practitioners, heart failure nurses, care home staff, and residents towards heart failure diagnosis and management for older people in long-term care: a qualitative interview study. BMC Geriatr 2013; 13:69. [PMID: 23829674 PMCID: PMC3723951 DOI: 10.1186/1471-2318-13-69] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2012] [Accepted: 06/27/2013] [Indexed: 11/10/2022] Open
Abstract
Background Older people in care-facilities may be less likely to access gold standard diagnosis and treatment for heart failure (HF) than non residents; little is understood about the factors that influence this variability. This study aimed to examine the experiences and expectations of clinicians, care-facility staff and residents in interpreting suspected symptoms of HF and deciding whether and how to intervene. Methods This was a nested qualitative study using in-depth interviews with older residents with a diagnosis of heart failure (n=17), care-facility staff (n=8), HF nurses (n=3) and general practitioners (n=5). Results Participants identified a lack of clear lines of responsibility in providing HF care in care-facilities. Many clinical staff expressed negative assumptions about the acceptability and utility of interventions, and inappropriately moderated residents’ access to HF diagnosis and treatment. Care-facility staff and residents welcomed intervention but experienced a lack of opportunity for dialogue about the balance of risks and benefits. Most residents wanted to be involved in healthcare decisions but physical, social and organisational barriers precluded this. An onsite HF service offered a potential solution and proved to be acceptable to residents and care-facility staff. Conclusions HF diagnosis and management is of variable quality in long-term care. Conflicting expectations and a lack of co-ordinated responsibility for care, contribute to a culture of benign neglect that excludes the wishes and needs of residents. A greater focus on rights, responsibilities and co-ordination may improve healthcare quality for older people in care. Trial registration ISRCTN: ISRCTN19781227
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Affiliation(s)
- Helen Close
- Durham Clinical Trials Unit, School of Medicine, Pharmacy and Health, Durham University, Queen's Campus, Wolfson Research Institute, University Boulevard, Stockton-on-Tees TS17 6BH, UK.
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Leening MJG, Deckers JW, Stricker BHC. Screening for heart failure in the elderly and the competition of co-morbidity. What if we could prevent heart failure from reaching the finish line first? Eur J Heart Fail 2013; 15:477. [PMID: 23429974 DOI: 10.1093/eurjhf/hft030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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