Prevalence of left ventricular systolic dysfunction and heart failure in high risk patients: community based epidemiological study

Opportunistic screening for asymptomatic left ventricular dysfunction in type 2 diabetes mellitus

BACKGROUND

International guidelines recommend natriuretic peptide biomarker-based screening for patients at high heart failure (HF) risk to allow early detection. There have been few reports about the incorporation of screening procedure to existing clinical practice.

OBJECTIVE

To implement screening of left ventricular dysfunction in patients with type 2 diabetes mellitus (DM).

METHOD

A prospective screening study at the DM complication screening centre was performed.

RESULTS

Between 2018 and 2019, 1043 patients (age: 63.7±12.4 years; male: 56.3%) with mean glycated haemoglobin of 7.25%±1.34% were recruited. 81.8% patients had concomitant hypertension, 31.1% had coronary artery disease, 8.0% had previous stroke, 5.5% had peripheral artery disease and 30.7% had chronic kidney disease (CKD) stages 3-5. 43 patients (4.1%) had an elevated N-terminal prohormone of brain natriuretic peptide (NT-proBNP) concentration above the age-specific diagnostic thresholds for HF, and 43 patients (4.1%) had newly detected atrial fibrillation (AF). The prevalence of elevated NT-proBNP increased with age from 0.85% in patients aged <50 years to 7.14% in those aged 70-79 years and worsening kidney function from 0.43% in patients with CKD stage 1 to 42.86% in CKD stage 5. In multivariate logistic regression, male gender (OR: 3.67 (1.47-9.16), p = 0.005*), prior stroke (OR: 3.26 (1.38-7.69), p = 0.007*), CKD (p<0.001*) and newly detected AF (OR: 7.02 (2.65-18.57), p<0.001*) were significantly associated with elevated NT-proBNP. Among patients with elevated NT-proBNP, their mean left ventricular ejection fraction (LVEF) was 51.4%±14.7%, and 45% patients had an LVEF <50%.

CONCLUSION

NT-proBNP and ECG screening could be implemented with relative ease to facilitate early detection of cardiovascular complication and improve long-term outcomes.

PULSE-HF: A Simple Clinical and Geriatric Score to Predict Systolic Dysfunction in the Elderly Without Heart Failure

To develop a clinical score to determine preclinical predictors of systolic dysfunction in an outpatient elderly population without a diagnosis of heart failure (HF). PULSE-HF is a cross-sectional study in elderly at-risk (coronary artery disease, diabetes or hypertension) outpatients without a diagnosis of heart failure (HF). The objective in this population was to develop a clinical score to determine preclinical predictors of systolic dysfunction. Clinical and geriatric variables were analyzed; independent predictive factors in the logistic regression analysis were included for the score calculation. Of the 722 subjects enrolled, 47 (6.5%) had a left ventricular ejection fraction (LVEF) < 50%, and 15 (2.1%) a LVEF < 40%. Mean age was 76.5 years (5.18) and 445 (61.6%) were female. Multiple logistic regression analysis identified abnormal Q waves (odds ratio [OR]: 4.36; P = 0.003), cardiomegaly (OR: 3.32; P < 0.001), right bundle branch block (OR: 2.84; P = 0.011), cognitive dysfunction (OR: 2.14; P = 0.027) and NT-proBNP (OR 5.43; P < 0.001) as independent predictors of LVEF < 50%. Two prediction scores were built, without and with NT-proBNP inclusion; the area under ROC curves were 0.70 and 0.76, respectively. As the score increased, the sensitivity decreases but increases specificity, and accuracy (97.17% and 91.64% respectively in ≥6 points). NT-proBNP was associated with an increment in the performance (accuracy of 93.18% for score ≥10). We conclude that a simple score using clinical information might be useful to predicting asymptomatic systolic dysfunction in the elderly.

Serum B-type natriuretic peptide in the initial workup of patients with new onset ascites: a diagnostic accuracy study

Heart failure (HF) is, after cirrhosis, the second-most common cause of ascites. Serum B-type natriuretic peptide (BNP) plays an important role in the diagnosis of HF. Therefore, we hypothesized that BNP would be useful in the differential diagnosis of ascites. Consecutive patients with new onset ascites were prospectively enrolled in this cross-sectional study. All patients had measurements of serum-ascites albumin gradient (SAAG), total protein concentration in ascitic fluid, serum, and ascites BNP. We enrolled 218 consecutive patients with ascites resulting from HF (n = 44), cirrhosis (n = 162), peritoneal disease (n = 10), and constrictive pericarditis (n = 2). Compared to SAAG and/or total protein concentration in ascites, the test that best discriminated HF-related ascites from other causes of ascites was serum BNP. A cutoff of >364 pg/mL (sensitivity 98%, specificity 99%, and diagnostic accuracy 99%) had the highest positive likelihood ratio (168.1); that is, it was the best to rule in HF-related ascites. Conversely, a cutoff ≤ 182 pg/mL had the lowest negative likelihood ratio (0.0) and was the best to rule out HF-related ascites. These findings were confirmed in a 60-patient validation cohort.

CONCLUSIONS

Serum BNP is more accurate than ascites analyses in the diagnosis of HF-related ascites. The workup of patients with new onset ascites could be streamlined by obtaining serum BNP as an initial test and could forego the need for diagnostic paracentesis, particularly in cases where the cause of ascites is uncertain and/or could be the result of HF.

The increasing detection of asymptomatic left ventricular dysfunction in patients with type 2 diabetes mellitus without overt cardiac disease: data from the SHORTWAVE study

AIMS

Type 2 diabetes mellitus (DM) is associated with higher risk of heart failure. Over the last three decades several studies demonstrated the presence of asymptomatic systolic and/or diastolic left ventricular (LV) dysfunction (asymLVD) in patients with normal LV ejection fraction (LVEF). Purpose of our study was to assess the prevalence and factors associated with asymLVD in DM patients by echocardiographic indexes more sensitive than LVEF and transmitral flow detected by pulsed Doppler.

METHODS

386 DM patients without overt cardiac disease were enrolled from January to October 2011. Stress-corrected midwall shortening (sc-MS) and mitral annular peak systolic velocity (S') were considered as indexes of systolic function of circumferential and longitudinal myocardial fibers, respectively. Early diastolic velocity of transmitral flow was divided by early diastolic Tissue Doppler velocity of mitral annulus for identifying diastolic LVD.

RESULTS

asymLVD was detected in 262 patients (68%). 106 (27%) had isolated systolic asymLVD, 61 (16%) isolated diastolic asymLVD; in 95 (25%) systolic and diastolic asymLVD coexisted. Patients with asymLVD were older, had lower glomerular filtration rate, higher levels of glycated hemoglobin, C reactive protein, LV mass, relative wall thickness and prevalence of valve calcifications. Older age (HR 1.1 [1.02-1.18], p=0.01), aortic valve calcifications (HR 6.3 [1.31-30.31], p=0.02), LV concentric geometry defined as relative wall thickness ≥0.43 (HR 15.44 [2.96-80.44], p=0.001) were independent predictors of asymLVD at multivariate analysis.

CONCLUSIONS

Using suitable echocardiographic indexes, asymLVD is detectable in two/third of DM patients without overt cardiac disease and is predicted by older age, cardiac valve calcifications and LV concentric remodeling.

Psychometric testing of the Self-Care of Heart Failure Index Version 6.2

The Self-Care of Heart Failure Index Version 6.2 (SCHFI v.6.2) is widely used, but its psychometric profile is still questioned. In a sample of 659 heart failure patients from Italy, we performed confirmatory factor analysis (CFA) to test the original construct of the SCHFI v.6.2 scales (Self-Care Maintenance, Self-Care Management, and Self-Care Confidence), with limited success. We then used exploratory factor analysis to determine the presence of separate scale dimensions, followed by CFA in a separate sub-sample. Construct validity of individual scales showed excellent fit indices: CFI = .92, RMSEA = .05 for the Self-Care Maintenance Scale; CFI = .95, RMSEA = .07 for the Self-Care Management Scale; CFI = .99, RMSEA = .02 for the Self-Care Confidence scale. Contrasting groups validity, internal consistency, and test-retest reliability were supported as well. This evidence provides a new understanding of the structure of the SCHFI v.6.2 and supports its use in clinical practice and research.

Epidemiology of Diabetes

The incidence of diabetes mellitus, particularly type 2 diabetes, is increasing dramatically in the United States and in other Westernized, industrialized societies because of increasing obesity, sedentary lifestyle, and population aging. There are currently 20 million persons with diabetes in the United States, of whom more than 5 million remain undiagnosed. The diabetic population consumes a disproportionate share of health care resources because of both microvascular and macrovascular complications. Diabetes is a major cause of new-onset blindness, end-stage renal disease, and nontraumatic amputation in the United States. Cardiovascular disease accounts for up to 80% of premature excess mortality in diabetic patients. Strategies to lessen the disease burden in these patients include hygienic measures (diet and exercise) as well as rigorous treatment of hypertension, dyslipidemia, and hyperglycemia.

Repeated assessment of physical biomeasures or blood biomarkers for the definition of volume status and cardiac loading in LVSD

The application of biomarker technology can be usefully implemented in areas where current techniques are inadequate and where a clinical issue, which affects outcome, can be defined. The definition of the loading status of the heart where there is pre-existent impairment of contractile function is a key target. Heart failure is a complex clinical presentation with many varied etiologies, but at the essence of its successful management is the reliable definition of cardiac volume loading. Traditional and many current technological measures are applied to define this relationship, yet their accuracy and performance in individual patients is either basically inadequate or poorly understood and applied. There is a wide range of both physical measurements and blood biomarkers that can be considered to better define this key issue in patients with ventricular systolic impairment. Their performance is considered in detail in this review.

Relationship between recommended chronic heart failure treatments and mortality over 8 years in real-world conditions: a pharmacoepidemiological study

PURPOSE

We previously reported that chronic heart failure (CHF) treatments reduce the duration of hospitalisation, even in elderly patients. The present study aimed to determine whether CHF treatment also provides long-term benefits in terms of reduced mortality at 8 years.

METHODS

A cohort of 281 patients who were admitted to a French teaching hospital with a main diagnosis of CHF were followed through the health insurance databases for 1 year and through the national mortality database for 8 years.

RESULTS

Diuretics (236 patients, 84 %) and angiotensin-converting enzyme (ACE) inhibitors (193 patients, 69 %) were the most-frequently prescribed medications. The median duration of survival was 46 months. Mortality rates were significantly lower for patients administered beta-blockers (59 %) and statins (56 %) than for patients not exposed to these drugs (82 %, p < 0.001 and 78 %, p = 0.001 respectively). No significant differences in mortality were observed for spironolactone, diuretics or ACE inhibitors. After adjustment, beta-blocker treatment remained associated with a significantly lower risk of mortality (hazard ratio, HR = 0.54 [0.34-0.84]). After adjustment, the use of two or three CHF drugs was associated with longer survival (HR = 0.53 [0.36-0.77]) than the use of zero or one CHF drug. Statins were also associated with longer survival after adjustment (HR = 0.53 [0.31-0.89]). In patients 75 years of age or older (n = 73), only beta-blocker treatment was associated with a significantly lower risk of mortality (HR = 0.31 [0.16-0.63]) in multivariate analysis.

CONCLUSIONS

The use of beta-blockers was associated with better survival rates. The use of statins was also associated with better survival at 8 years. Randomised controlled trials are required to confirm these observations.

Prevalence of conduction abnormalities in a systolic heart failure population by race, ethnicity, and gender

BACKGROUND

There is paucity of data regarding conduction abnormalities in the Hispanic population with systolic heart failure (HF). We aimed to evaluate the prevalence of electrocardiogram (ECG) abnormalities in a systolic HF population, with attention to the Hispanic population.

METHODS

A cross sectional study of 926 patients enrolled in a systolic HF disease management program. ECGS were obtained in patients with an ejection fraction (EF) ≤ 40% by echocardiography at enrollment. Univariate and multivariate analysis adjusted by ethnicities was performed.

RESULTS

White patients exhibited higher prevalence of atrial fibrillation (14.7%) than black patients (8.0%, P = 0.01) whereas Hispanics presented higher prevalence of paced rhythm (14.3% in Hispanics vs. 6.5% in whites and 5.2% in blacks, P<0.01 for both comparisons), higher prevalence of left bundle branch block (LBBB, 14.5% in Hispanics vs. 8.8% in whites and 5.8% in blacks, P = 0.002) and increased frequency of abnormal QT intervals (76.7% in Hispanics) than whites (59.6%) and blacks (69%) patients (P< 0.01 for both comparisons). A QRS interval greater than 120 ms was less prevalent among blacks (15.8% vs. 26.0% in whites and 25.3% in Hispanics, P = 0.01 for both comparisons). Univariate and multivariate analysis disclosed no influence of other characteristics (age, sex, coronary artery disease, hypertension, ejection fraction, medications) in the ECG findings.

CONCLUSIONS

Hispanics with Systolic HF presented with increased prevalence of paced rhythm, LBBB, and abnormal QT intervals. Attention should be addressed to these ECG variations to recommend additional guidance for therapeutic interventions and provide important prognostic information.

High prevalence of previously unknown heart failure and left ventricular dysfunction in patients with type 2 diabetes

AIMS/HYPOTHESIS

The aim of this study was to assess the prevalence of (unknown) heart failure and left ventricular dysfunction in older patients with type 2 diabetes.

METHODS

In total, 605 patients aged 60 years or over with type 2 diabetes in the south west of the Netherlands participated in this cross-sectional study (response rate 48.7%), including 24 with a cardiologist-confirmed diagnosis of heart failure. Between February 2009 and March 2010, the patients without known heart failure underwent a standardised diagnostic work-up, including medical history, physical examination, ECG and echocardiography. An expert panel used the criteria of the European Society of Cardiology to diagnose heart failure.

RESULTS

Of the 581 patients studied, 161 (27.7%; 95% CI 24.1%, 31.4%) were found to have previously unknown heart failure: 28 (4.8%; 95% CI 3.1%, 6.6%) with reduced ejection fraction, and 133 (22.9%; 95% CI 19.5%, 26.3%) with preserved ejection fraction. The prevalence of heart failure increased steeply with age. Heart failure with preserved ejection fraction was more common in women. Left ventricular dysfunction was diagnosed in 150 patients (25.8%; 95% CI 22.3%, 29.4%); 146 (25.1%; 95% CI 21.6%, 28.7%) had diastolic dysfunction.

CONCLUSIONS/INTERPRETATION

This is the first epidemiological study that provides exact prevalence estimates of (previously unknown) heart failure and left ventricular dysfunction in a representative sample of patients with type 2 diabetes. Previously unknown heart failure and left ventricular dysfunction are highly prevalent. Physicians should pay special attention to 'unmasking' these patients.

Systolic heart failure in South Asians

Heart failure (HF) is a common condition leading to an unfavourable prognosis and impaired quality of life. In this review, we provide an overview of published literature on possible epidemiological and pathophysiological differences between patients with systolic HF of South Asian origin and those from other ethnic groups (mainly White). Systolic HF tends to manifest earlier among South Asians and with frequent hospital admissions. However, survival for such patients appears to be significantly better compared with the White group, which might be associated with different patterns of HF. For example, this could be attributed to a lower prevalence of left ventricular systolic dysfunction in South Asian subjects. Indeed, the high prevalence of hypertension and diabetes among South Asians may predispose to diastolic HF with preserved systolic function. In addition, because of underrepresentation of South Asians in clinical trials, there are little data on optimal management of this ethnic group.

Ethnic differences in macrovascular and microvascular function in systolic heart failure

BACKGROUND

Endothelial dysfunction is implicated in the pathophysiological features of heart failure (HF), and ethnic differences in the presentation of cardiovascular disease are evident, with an excess seen among South Asians (SAs). However, data on ethnic differences in endothelial function in HF are limited.

METHODS AND RESULTS

In a cross-sectional study, we recruited 128 subjects with systolic HF: 50 SAs, 50 whites, and 28 African Caribbeans (ACs). In addition, SAs with systolic HF were compared with 40 SAs with coronary artery disease without HF ("disease controls") and 40 SA healthy controls. Macrovascular endothelial function was assessed by measurement of flow-mediated dilation (FMD) in response to hyperemia, arterial stiffness was assessed by the pulse-wave velocity, and microvascular endothelial function was assessed by forearm laser Doppler flowmetry. CD144-expressing endothelial microparticles were measured by flow cytometry. When compared with disease controls and healthy controls, SAs with HF had an impaired microvascular response to acetylcholine (P=0.001) and reduced FMD (P<0.001). In comparing ethnic groups, SAs with HF had an impaired response to acetylcholine (123±95.5%) compared with whites (258±156%) and ACs (286±173%, P<0.001 for both). Whites had a higher FMD (8.49±4.63%) than SAs (4.76±4.78%, P<0.001) and ACs (4.55±3.56%, P=0.01). No difference in endothelial-independent response was observed between study groups or in pulse-wave velocity. Ethnicity remained associated with microvascular endothelial function even after adjustment for age, presence of hypertension and diabetes mellitus, blood pressure, and glucose levels (P=0.003). There were no differences in numbers of endothelial microparticles.

CONCLUSIONS

The SAs with HF have impaired microvascular and macrovascular endothelial function but preserved arterial elastic properties. Significant ethnic differences in endothelial function are evident in subjects with HF, with ethnicity being associated with microvascular endothelial dysfunction in this disorder.

Identification of patients with asymptomatic left ventricular dysfunction: 'real practice' results in primary care

AIMS

Asymptomatic systolic left ventricular dysfunction (ASLVD) fulfills the essential criteria to screen for a disease. In Italy, echocardiography screening has been suggested for high-risk patients, albeit not tested in 'real practice'.

OBJECTIVE

We evaluated the feasibility and the results of such a strategy in primary care.

METHODS AND RESULTS

Seventy Italian GPs first identified all their 50- to 74-year-old patients with coronary heart disease and/or hypertension and/or diabetes mellitus and/or renal damage, then randomly selected 1405 individuals (one-tenth). In this group, 217 (15%) hypertensive and diabetic patients had no end organ damage evaluation, could not be classified as high/non-high-risk and had no prescription for echocardiogram; 390 individuals [27.7%; 95% confidence interval (CI) 25.4-30%) resulted as high risk. A recent echocardiogram was already available in 129 (33.1%) patients, 122 (31.3%) underwent echocardiography and 139 (35.6%) did not comply with this prescription. Non-compliance and difficult access to echocardiography were the main reasons not to undergo the prescribed echocardiogram. Among the 261 evaluable subjects, 26 (10.8%; 95% CI 7-14.6%) had a <or=50% and 10 (4.0%; 95% CI 1.6-6.4%) a <or=40% left ventricular ejection fraction. Only 5 out of 26 ASLVD cases where detected by echocardiograms performed for pure screening purposes.

CONCLUSION

Only a third of high-risk patients may benefit from screening, with a modest gain over current practice in terms of new ASLVD diagnoses.

Long-term association between self-reported signs and symptoms and heart failure hospitalizations: the Atherosclerosis Risk In Communities (ARIC) Study

AIMS

Although studies of the accuracy of heart failure (HF) classification scoring systems are available, few have examined their performance when restricted to self-reported items.

METHODS AND RESULTS

We evaluated the association between a simplified version of the Gothenburg score, a validated HF score comprised of cardiac and pulmonary signs and symptoms and medication use, and incident HF hospitalizations in 15,430 Atherosclerosis Risk in Communities (ARIC) Study participants. Gothenburg scores (range: 0-3) were constructed using self-reported items obtained at study baseline (1987-89). Incident HF hospitalization over 14.7 years of follow-up was defined as the first identified hospitalization with an ICD-9 discharge code of 428 (n = 1,668). Self-reported Gothenburg scores demonstrated very high agreement with the original metric comprised of self-reported and clinical measures and were directly associated with incident HF hospitalizations: [score = 1: hazard rate ratio (HRR) = 1.23 (1.07-1.42); score = 2: HRR = 2.17 (1.92-2.43); score = 3: HRR = 3.98 (3.37-4.70)].

CONCLUSION

In a population-based cohort, self-reported Gothenburg criteria items were associated with hospitalized HF over a prolonged follow-up time. The association was also consistent across groups defined by sex and race, suggesting that this simple score deserves further study as a screening tool for the identification of individuals at high risk of HF in resource-limited settings.

Validity of a discharge diagnosis of heart failure: implications of misdiagnosing

Heart failure (HF) costs are largely due to hospitalization. The validity of a death/discharge diagnosis of HF (DDHF) is largely unknown. The authors assessed the validity of DDHF and the impact of misdiagnosing. The case notes of patients consecutively admitted to a medical department between January and June 2001 were reviewed. Cases with DDHF or cardiovascular diseases, potential precursors of HF (PPHF), were included. The diagnosis of HF (European Society of Cardiology guidelines) was classified as definite, possible, or miscoded. Of the 1038 patients admitted, 234 were enrolled: 157 with DDHF and 77 with PPHF. One hundred eighty patients had a definite diagnosis of HF. Of the 157 diagnoses coded as definite HF, 130 were correct, 21 had possible HF, and 6 were miscoded. Of the 77 patients classified as having PPHF, 38 had definite HF. The accuracy of the DDHF diagnosis was 72.2%: 21.1% were underdiagnosed and 8.3% overdiagnosed. DDHF failed to capture many HF admissions and therefore alone underestimates the prevalence, burden, and costs of the syndrome.

Prevalence and prognosis of left ventricular systolic dysfunction in asymptomatic diabetic patients without known coronary artery disease referred for stress single-photon emission computed tomography and assessment of left ventricular function

BACKGROUND

The prevalence and prognosis of reduced left ventricular ejection fraction (LVEF) in asymptomatic diabetic patients without known coronary artery disease (CAD) are not known.

METHODS

We examined 1046 asymptomatic diabetic patients (age 60 +/- 13 years, 69% male) without known CAD referred to a tertiary referral center for stress single-photon emission computed tomography (SPECT) and assessment of LVEF. Patients were stratified according to the presence of normal LVEF (> or = 50%), mildly reduced LVEF (35%-49%), or moderately/severely reduced LVEF (< 35%). Single-photon emission computed tomographic images were classified as low, intermediate, or high risk based on the summed stress score (normal = 56). The mean follow-up was 5.3 +/- 3.3 years.

RESULTS

The prevalence of reduced LVEF was 16.7% (n = 175, mean LVEF 40.0% +/- 7.7%). This group was older (63 +/- 11 vs 59 +/- 14 years, P = .005), had more peripheral arterial disease (45% vs 29%, P < .001), and had a higher prevalence of electrocardiographic Q waves (21% vs 9%, P < .001) than the group without reduced LVEF. Mean summed stress (44.8 +/- 9.8 vs 51.7 +/- 6.3, P < .001), summed reversibility (4.7 +/- 5.0 vs 2.9 +/- 4.5, P < .001), and summed rest scores (49.4 +/- 7.2 vs 54.6 +/- 3.1, P < .001) were significantly more abnormal in the reduced LVEF group. High-risk summed stress score was significantly more common in the reduced LVEF group (46% vs 16%, P < .001). Survival was significantly lower in patients with any reduction in LVEF compared with those without reduced LVEF (10-year survival, 29% vs 57%, P < .0001). By multivariate analysis, reduced LVEF was independently associated with increased mortality (adjusted chi2 = 6.26, P = .01).

CONCLUSIONS

In this population of asymptomatic diabetic patients without known CAD referred for stress SPECT, 1 in 6 patients had reduced LVEF. Most of these patients have intermediate-/high-risk SPECT scans. The annual mortality rates of the groups with and without reduced LVEF were 7% and 4%, respectively.

Screening versus routine practice in detection of atrial fibrillation in patients aged 65 or over: cluster randomised controlled trial

OBJECTIVES

To assess whether screening improves the detection of atrial fibrillation (cluster randomisation) and to compare systematic and opportunistic screening.

DESIGN

Multicentred cluster randomised controlled trial, with subsidiary trial embedded within the intervention arm.

SETTING

50 primary care centres in England, with further individual randomisation of patients in the intervention practices.

PARTICIPANTS

14,802 patients aged 65 or over in 25 intervention and 25 control practices.

INTERVENTIONS

Patients in intervention practices were randomly allocated to systematic screening (invitation for electrocardiography) or opportunistic screening (pulse taking and invitation for electrocardiography if the pulse was irregular). Screening took place over 12 months in each practice from October 2001 to February 2003. No active screening took place in control practices.

MAIN OUTCOME MEASURE

Newly identified atrial fibrillation.

RESULTS

The detection rate of new cases of atrial fibrillation was 1.63% a year in the intervention practices and 1.04% in control practices (difference 0.59%, 95% confidence interval 0.20% to 0.98%). Systematic and opportunistic screening detected similar numbers of new cases (1.62% v 1.64%, difference 0.02%, -0.5% to 0.5%).

CONCLUSION

Active screening for atrial fibrillation detects additional cases over current practice. The preferred method of screening in patients aged 65 or over in primary care is opportunistic pulse taking with follow-up electrocardiography.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN19633732 [controlled-trials.com].

Telemonitoring or structured telephone support programmes for patients with chronic heart failure: systematic review and meta-analysis

OBJECTIVE

To determine whether remote monitoring (structured telephone support or telemonitoring) without regular clinic or home visits improves outcomes for patients with chronic heart failure.

DATA SOURCES

15 electronic databases, hand searches of previous studies, and contact with authors and experts.

DATA EXTRACTION

Two investigators independently screened the results.

REVIEW METHODS

Published randomised controlled trials comparing remote monitoring programmes with usual care in patients with chronic heart failure managed within the community.

RESULTS

14 randomised controlled trials (4264 patients) of remote monitoring met the inclusion criteria: four evaluated telemonitoring, nine evaluated structured telephone support, and one evaluated both. Remote monitoring programmes reduced the rates of admission to hospital for chronic heart failure by 21% (95% confidence interval 11% to 31%) and all cause mortality by 20% (8% to 31%); of the six trials evaluating health related quality of life three reported significant benefits with remote monitoring, and of the four studies examining healthcare costs with structured telephone support three reported reduced cost and one no effect.

CONCLUSION

Programmes for chronic heart failure that include remote monitoring have a positive effect on clinical outcomes in community dwelling patients with chronic heart failure.

Historical trends in survival of hospitalized heart failure patients: 2000 versus 1995

BACKGROUND

Population-based secular trends in survival of patients with congestive heart failure (CHF) are central to public health research on the burden of the syndrome.

METHODS

Patients 35-79 years old with a CHF discharge code in 1995 or 2000 were identified in 22 Minneapolis-St. Paul hospitals. A sample of the records was abstracted (50% of 1995 records; 38% of 2000 records). A total of 2,257 patients in 1995 and 1,825 patients in 2000 were determined to have had a CHF-related hospitalization. Each patient was followed for one year to ascertain vital status.

RESULTS

The risk profile of the 2000 patient cohort was somewhat worse than that of the 1995 cohort in both sex groups, but the distributions of age and left ventricular ejection fraction were similar. Within one year of admission in 2000, 28% of male patients and 27% of female patients have died, compared to 36% and 27% of their counterparts in 1995, respectively. In various Cox regression models the average year effect (2000 vs. 1995) was around 0.75 for men and 0.95 to 1.00 for women. The use of angiotensin converting-enzyme inhibitors and beta-blockers was associated with substantially lower hazard of death during the subsequent year.

CONCLUSION

Survival of men who were hospitalized for CHF has improved during the second half of the 1990s. The trend in women was very weak, compatible with little to no change. Documented benefits of angiotensin converting-enzyme inhibitors and beta-blockers were evident in these observational data in both men and women.

Communication in heart failure: perspectives from older people and primary care professionals

The objective of this study was to explore the attitudes of older people and primary care professionals towards communication of diagnosis, prognosis and symptoms in heart failure. Forty-four interviews were conducted with people aged>60 years with heart failure (New York Heart Association III-IV) recruited from general practices in the UK. Ten focus groups were held with primary care professionals involved in heart failure management. Data were analysed thematically with the aid of the NUD*IST computer program. Participants reported problems with communication, including not being given enough information about their condition, or being given complex information that they did not understand. Many understood little about heart failure and the causes of, and ways to manage, their symptoms. Few participants had had discussions about the prognosis with any health professional, and this was confirmed in professional accounts. Difficulties with terminology were frequently reported: a diagnosis of 'heart failure' was rarely communicated to patients to avoid causing anxiety. Educational needs were identified by most primary care professionals in relation to heart failure management and specifically in relation to communication. In conclusion, communication was identified as being inadequate within primary care from both the patient and professional perspectives. These findings point to a need for an educational intervention tailored specifically to the need to improve the communication skills of primary care professionals in chronic heart failure.

Do discharge codes underestimate hospitalisation due to heart failure? Validation study of hospital discharge coding for heart failure

BACKGROUND

Discharge codes are frequently used to describe hospital activity related to heart failure (HF).

OBJECTIVES

To determine whether discharge codes for HF underestimated or overestimated hospital activity related to HF.

DESIGN

Patients with atrial fibrillation (AF), who commonly have HF, were identified and their case notes reviewed to identify cases of HF missed by discharge codes.

PARTICIPANTS AND METHODS

Patients admitted between November 1997 and January 1998 with either HF or AF. Identification of HF and AF by ICD10 hospital discharge codes. Identification of additional cases of AF from a central hospital-wide ECG database.

RESULTS

We identified 330 cases with an ICD 10 code for HF, of which 43 (13%) were deemed to be miscoded, 32 patients (10%) were classified as possible, 39 (12%) as probable and 216 (65%) as definite HF. Results were similar whether or not HF was the primary discharge diagnosis. We identified 452 patients with AF, of whom 45 (10%) were classified as probable and 193 (43%) as definite HF. 129 (54%) of these cases had no diagnostic discharge code for HF. ICD 10 discharge codes for HF were correct in 77% of cases but identified only 66% of patients with probable or definite HF in this analysis. Screening of other diagnoses would have identified further cases of HF.

CONCLUSIONS

Hospital discharge codes substantially underestimate hospital events related to HF in the UK.

Recruiting older people into a large, community-based study of heart failure

This paper highlights some of the challenges encountered when recruiting older people with heart failure into longitudinal, community-based research. It draws on the experience gained in a study to provide insights into the palliative care needs of older people with heart failure and the timing and need for service interventions. Five hundred and forty-two people with heart failure (New York Heart Association (NYHA) stages II-IV) and 213 of their informal carers were recruited from primary care practices in four areas of the UK. Ethical issues arising around gate-keeping, terminology and participant burden are discussed along with challenges faced during the recruitment process. Strategies to increase general practitioner and patient recruitment are provided. The paper concludes that prospective longitudinal studies are of particular relevance to chronic illness, and the complexity of setting up such research must be acknowledged and appropriately resourced.

Anticoagulation in patients with non-valvular atrial fibrillation: an evaluation of stability and early factors that predict longer-term stability on warfarin in a large UK population

OBJECTIVE

To determine the proportion of patients with non-valvular atrial fibrillation (NVAF) treated with warfarin that achieved a 6-month period within the target INR range (stability). To then evaluate any associations between stability and outcome and to determine whether stability can be predicted by clinical factors at an early stage in warfarin treatment.

METHODS

This study was a record linkage study in 1513 patients with NVAF treated with warfarin for a minimum of 6-months, carried out in a large UK population. The main outcome measures were stability (defined as six months within the target INR range [2.0-3.0]), thromboembolic and bleeding event rates and mortality. Secondary outcome measures were the predictive value of baseline characteristics and other treatment variables.

RESULTS

Stability was achieved in 52% of the study group. Standardised mean survival was significantly higher in the group who achieved stability (Delta = 16.91 months, p < 0.001) with a hazard ratio of 4.36 (p < 0.001). The stable group had a lower rate of both thromboembolic events (0.8% vs. 2.3% per patient year) and bleeds recorded on inpatient diagnoses (0.4% vs. 1.2% per patient year). Failure to achieve stable control was associated with age (Odds Ratio [OR] 1.011 (95% Confidence Interval [CI] 1.001-1.021)) and morbidity at baseline (OR 1.015; 95% CI 1.007-1.022). An increase in mean time between visits (OR 0.939; 95% CI 0.926-0.952) and the percentage time in range (OR 0.889; 95% CI 0.879-0.900) was associated with a decrease in the chance of instability. Greater variability in INR was also associated with a failure to achieve stability (OR 1.518; 95% CI 1.427-1.615). Receiver Operator Characteristic (ROC) analysis using data from the first three months of treatment demonstrated good discrimination of stability using age and morbidity at baseline and percentage time in range and frequency of visits during the first three months of treatment (area under curve [AUC] 0.780; standard error [SE] 0.012; 95% CI 0.757-0.803).

CONCLUSIONS

Many patients never achieved a period of 6-months stability and were at increased risk of thromboembolic events and bleeds. Age, morbidity at baseline and variability of INR control in the first three months could be used to predict instability using warfarin. This study infers that patients should be treated more intensively in the early stages of warfarinisation in order to improve outcome.

Utilisation of medications recommended for chronic heart failure and the relationship with annual hospitalisation duration in patients over 75 years of age. A pharmacoepidemiological study

OBJECTIVES

Trials in chronic heart failure (CHF) include few patients older than 75 years, who represent a large proportion of CHF patients. We evaluated the influence of age on CHF-medication use and of CHF medications on hospitalisation in patients older than 75 years.

METHODS

Included in our nested case-control study were 281 patients admitted in 2000 to a French teaching hospital with a main diagnosis of CHF and monitored over a 12-month period. Patient characteristics, medications at discharge, outpatient medications and hospitalisation frequency and duration were compared by means of univariate and multivariate analyses.

RESULTS

Patients older than 75 years (n=150) and 75 years or younger (n=131) were similar with regard to NYHA class and ejection fraction. At discharge, diuretic use was similar in the two groups, but fewer older patients were prescribed angiotensin-converting enzyme (ACE) inhibitors (48% versus 63%, P<0.01) or beta-blockers (19% versus 37%, P<0.001). During follow-up, total re-admission rate and mean number of re-admissions were similar; however, total hospitalisation duration was greater in patients older than 75 years (38+/-77 days) than in those 75 years or younger (26+/-59 days) (P<0.01). In patients over 75 years, shorter 12-month hospitalisation duration was associated with prescription of diuretics (P<0.001), ACE inhibitors (P<0.001), beta-blockers (P<0.01) and digitalis (P<0.05).

CONCLUSIONS

Recent advances in CHF therapy are generally applied less to patients over 75 years of age-associated with longer annual hospitalisation duration in this population. Appropriate CHF medications at hospital discharge appear to reduce annual hospitalisation duration in patients older than 75 years.

Economic burden of post-acute myocardial infarction heart failure in the United Kingdom

Congestive heart failure (CHF) is a major cause of morbidity and mortality. This study was carried out to quantify the burden of CHF, subsequent to acute myocardial infarction (AMI), from the perspective of the UK National Health Service (NHS). A systematic literature review of publications since 1990 was carried out on the economic burden of heart failure. The economic burden of post-AMI heart failure in the UK for the year 2000 was estimated for two scenarios: (1) Base-case estimate (post-AMI heart failure accounts for 20% of heart failure cases): Direct healthcare costs of pound 125-181 million (approx. 0.4% of total NHS spend) and nursing home costs of pound 27 million; (2) Upper estimate (post-AMI heart failure accounts for 50% of the total): Direct healthcare costs of pound 313-453 million (approx 1.0% of total NHS spend) and nursing home costs of pound 68 million. In conclusion, post-AMI heart failure imposes a significant direct economic burden on the UK.

Hospitalized heart failure: rates and long-term mortality

BACKGROUND

Heart failure has been called the "new epidemic of cardiovascular disease," but few studies have described key epidemiologic measures of the syndrome in geographically defined US populations.

METHODS AND RESULTS

We obtained lists of discharge diagnosis codes in 1995 from 22 Minneapolis-St. Paul metropolitan area hospitals; identified patients 35 to 84 years old with a heart failure discharge code; and sampled and abstracted 50% of the hospital records. To identify heart failure-related hospitalizations, we applied 6 published definitions of the syndrome to the sample and selected cases that met at least 4 of the 6 definitions (n = 2887). The patient cohort was followed for 5 to 6 years to ascertain deaths. The rate of hospitalized heart failure ranged from a few dozen hospitalized patients per 100,000 residents ages 35 to 44 years to more than 2000 per 100,000 residents ages 75 to 84, and was consistently higher among men than among women (age-adjusted rate ratio 1.46; 95% CI 1.39-1.54). Within 1-year of the index admission, 37% of male patients and 30% of female patients have died-10 times the annual mortality of the source population. By the end of the follow-up, cumulative mortality reached 72% in men and 66% in women. In multivariable regression of the hazard of death on age, sex, and left ventricular ejection fraction (LVEF), age was a strong determinant of mortality and male patients had modestly higher hazard of death than female patients (adjusted hazard ratio, 1.29; 95% CI 1.18-1.41). LVEF was not a strong predictor of death.

CONCLUSION

A heart failure-related hospitalization is a marker of grave prognosis: only one quarter to one third of the patients survives 5 years after admission. Both the risk of hospitalization for heart failure and the risk of subsequent death are moderately higher in men than in women. LVEF, when measured in the context of heart failure-related hospitalization, is not a strong predictor of death.

A randomised controlled trial and cost effectiveness study of systematic screening (targeted and total population screening) versus routine practice for the detection of atrial fibrillation in the over 65s: (SAFE) [ISRCTN19633732]

Background

Atrial fibrillation (AF) has been recognised as an important independent risk factor for thromboembolic disease, particularly stroke for which it provides a five-fold increase in risk. This study aimed to determine the baseline prevalence and the incidence of AF based on a variety of screening strategies and in doing so to evaluate the incremental cost-effectiveness of different screening strategies, including targeted or whole population screening, compared with routine clinical practice, for detection of AF in people aged 65 and over. The value of clinical assessment and echocardiography as additional methods of risk stratification for thromboembolic disease in patients with AF were also evaluated.

Methods

The study design was a multi-centre randomised controlled trial with a study population of patients aged 65 and over from 50 General Practices in the West Midlands. These purposefully selected general practices were randomly allocated to 25 intervention practices and 25 control practices. GPs and practice nurses within the intervention practices received education on the importance of AF detection and ECG interpretation. Patients in the intervention practices were randomly allocated to systematic (n = 5000) or opportunistic screening (n = 5000). Prospective identification of pre-existing risk factors for AF within the screened population enabled comparison between high risk targeted screening and total population screening. AF detection rates in systematically screened and opportunistically screened populations in the intervention practices were compared to AF detection rate in 5,000 patients in the control practices.

Heart failure prevalence, incidence, and mortality in the elderly with diabetes

OBJECTIVE

The goal of this study was to determine heart failure prevalence and incidence rates, subsequent mortality, and risk factors for heart failure among older populations in Medicare with diabetes.

RESEARCH DESIGN AND METHODS

We used a national 5% sample of Medicare claims from 1994 to 1999 to perform a population-based, nonconcurrent cohort study in 151,738 beneficiaries with diabetes who were age > or =65 years, not in managed care, and were alive on 1 January 1995. Prevalent heart failure was defined as a diagnosis of heart failure in 1994; incident heart failure was defined as a new diagnosis in 1995-1999 among those without prevalent heart failure. Mortality was assessed through 31 December 1999.

RESULTS

Heart failure was prevalent in 22.3% in 1994. Among individuals without heart failure in 1994, the heart failure incidence rate was 12.6 per 100 person-years (95% CI 12.5-12.7 per 100 person-years). Incidence was similar by sex and race and increased significantly with age and diabetes-related comorbidities. The adjusted hazard of incident heart failure increased for individuals with the following: metabolic complications of diabetes (a proxy for poor control and/or severity) (hazards ratio 1.23, 95% CI 1.18-1.29), ischemic heart disease (1.74, 1.70-1.79), nephropathy (1.55, 1.45-1.67), and peripheral vascular disease (1.35, 1.31-1.39). Over 60 months, incident heart failure among older adults with diabetes was associated with high mortality-32.7 per 100 person-years compared with 3.7 per 100 person-years among those with diabetes who remained heart failure free.

CONCLUSIONS

These data demonstrate alarmingly high prevalence, incidence, and mortality for heart failure in individuals with diabetes. Prevention of heart failure should be a research and clinical priority.