The DANish randomized, double-blind, placebo controlled trial in patients with chronic HEART failure (DANHEART): A 2 × 2 factorial trial of hydralazine-isosorbide dinitrate in patients with chronic heart failure (H-HeFT) and metformin in patients with chronic heart failure and diabetes or prediabetes (Met-HeFT)

OBJECTIVES

The DANHEART trial is a multicenter, randomized (1:1), parallel-group, double-blind, placebo-controlled study in chronic heart failure patients with reduced ejection fraction (HFrEF). This investigator driven study will include 1500 HFrEF patients and test in a 2 × 2 factorial design: 1) if hydralazine-isosorbide dinitrate reduces the incidence of death and hospitalization with worsening heart failure vs. placebo (H-HeFT) and 2) if metformin reduces the incidence of death, worsening heart failure, acute myocardial infarction, and stroke vs. placebo in patients with diabetes or prediabetes (Met-HeFT).

METHODS

Symptomatic, optimally treated HFrEF patients with LVEF ≤40% are randomized to active vs. placebo treatment. Patients can be randomized in either both H-HeFT and Met-HeFT or to only one of these study arms. In this event-driven study, it is anticipated that 1300 patients should be included in H-HeFT and 1100 in Met-HeFT and followed for an average of 4 years.

RESULTS

As of May 2020, 296 patients have been randomized at 20 centers in Denmark.

CONCLUSION

The H-HeFT and Met-HeFT studies will yield new knowledge about the potential benefit and safety of 2 commonly prescribed drugs with limited randomized data in patients with HFrEF.

Evaluation of telemedicine in patients suspected of acute coronary syndrome at a non-invasive centre

INTRODUCTION

The benefits of prehospital electrocardiograms (ECG) for patients with ST-elevation myocardial infarction (STEMI) are well-known. Evaluation of the present algorithm for prehospital ECG transmission is important to ensure correct and expeditious patient care. The purpose of this study was to evaluate ECGs transmitted from the prehospital setting to a non-invasive department of cardiology.

METHODS

At Lillebaelt Hospital, the cardiologist on-call evaluated and entered the transmitted ECGs and the associated transmission criteria into the Clinical Measurement System database (KMS). Furthermore, data from the KMS and the diagnoses at discharge were obtained from 2012 to 2015.

RESULTS

A total of 9,751 ECGs were included in the study. ECG transmission increased by 35% from year one to year three (p less-than 0.05). A total of 362 patients (3.7%) had STEMI. 25% of all ECGs were transmitted without any obvious cardiac symptom but produced a diagnosis of other cardiac illnesses than acute coronary syndrome in 28% of these patients. The number of ECGs sent per adult inhabitant in the area per year was 1:85.

CONCLUSIONS

A large number of ECGs are transmitted annually and at an increasing rate, and STEMI only comprises a very limited proportion of all transmitted ECGs to a non-invasive centre in Denmark. The high number of ECGs challenge the available resources, which are limited and should be used effectively, particularly in a period characterised by increased healthcare demands.

FUNDING

none.

TRIAL REGISTRATION

not relevant.

The First Steps Taken to Implement Palliative Care in Advanced Heart Disease: A Position Statement from Denmark

According to the World Health Organization, palliative care must be available for everyone with life-threatening diseases. However, in daily practice the primary focus worldwide is on cancer patients. The aim of the article was to generate a national position statement as the first step in implementing palliative care in severe heart disease with focus on advanced heart failure, including tools to identify the need for and timing of palliative care and how palliative care could be organized in Denmark. A task force was formed in the Danish Society of Cardiology Heart Failure Working Group, and the position statement was prepared in collaboration with members from a broad group of specialties, including palliative medicine. Because of major gaps in evidence, the position statement was based on small and low-quality studies and clinical practice statements. This position statement was aligned with the European Society of Cardiology recommendation, focusing on relieving suffering from the early disease stages parallel to standard care and supplementing life-prolonging treatment. The statement delivers practical guidance on clinical aspects and managing symptoms during the three stages of advanced heart disease. Furthermore, the statement describes the importance of communication and topics to be broached, including deactivating implantable cardioverter defibrillators. The statement recommends a targeted effort on organizational strategies using high-quality assessment tools and emphasizes multidisciplinary and intersectoral collaboration. Danish cardiologists supported by allied professionals acknowledge the importance of palliative care in advanced heart disease. This national position statement intended to inform and influence policy and practice and can hopefully inspire other countries to take action toward implementing palliative care in advanced heart disease.

[Palliative care is for everyone, even for patients with life-threatening medical organ failure]

Healthcare authorities have emphasised the need to develop palliative care for everybody suffering from life-threatening diseases, including people suffering from medical organ failure. In 2011, the Danish Health Authority requested that all medical associations developed guidelines for palliative care. Until now, this has been fulfilled by only four associations. The aim of this review is to summarise the status of the palliative care needs and palliative care across diagnosis for patients suffering from life-threatening medical organ failure and to draw attention to the lack of care and the importance of guidelines.

[Rehabilitation and palliative care in cardiovascular diseases in Denmark]

An increasing number of Danes are living, and dying, with cardiovascular disease. There is good evidence for the impact of cardiac rehabilitation on coronary heart disease, heart failure and symptomatic peripheral arterial disease. However, more high-quality research is needed into a wider range of cardiac diseases including rehabilitation following cardiac arrest, and palliative care for patients with advanced heart disease. In this review it is discussed how to improve the quality of care and identify the direction of future research and development.

Cardiac rehabilitation with a nurse case manager (GoHeart) across local and regional health authorities improves risk factors, self-care and psychosocial outcomes. A one-year follow-up study

OBJECTIVES

In Denmark, the local and regional health authorities share responsibility for cardiac rehabilitation (CR). The objective was to assess effectiveness of CR across sectors coordinated by a nurse case manager (NCM).

DESIGN

A one-year follow-up study.

SETTING

A CR programme (GoHeart) was evaluated in a cohort at Lillebaelt Hospital Vejle, DK from 2010 to 2011.

PARTICIPANTS

Consecutive patients admitted to CR were included. The inclusion criteria were the event of acute myocardial infarction or stable angina and invasive revascularization (left ventricular ejection fraction (LVEF) ≥45%).

MAIN OUTCOME MEASURES

Cardiac risk factors, stratified self-care and self-reported psychosocial factors (SF12 and Hospital Anxiety and Depression Scale (HADS)) were assessed at admission (phase IIa), at three months at discharge (phase IIb) and at one-year follow-up (phase III). Intention-to-treat and predefined subgroup analysis on sex was performed.

RESULTS

Of 241 patients, 183 (75.9%) were included (mean age 63.8 years). At discharge improvements were found in total-cholesterol (p < 0.001), low density lipoprotein (LDL; p < 0.001), functional capacities (metabolic equivalent of tasks (METS), p < 0.01), self-care management (p < 0.001), Health status Short Form 12 version (SF12; physical; p < 0.001 and mental; p < 0.01) and in depression symptoms (p < 0.01). At one-year follow-up these outcomes were maintained; additionally there was improvement in body mass index (BMI; p < 0.05), and high density lipoprotein (HDL; p < 0.05). There were no sex differences.

CONCLUSION

CR shared between local and regional health authorities led by a NCM (GoHeart) improves risk factors, self-care and psychosocial factors. Further improvements in most variables were at one-year follow-up.

[Inter-sectoral coordination of rehabilitation can reduce the number of dropouts from chronic heart disease courses]

The Department of Cardiology, Lillebælt Hospital, Vejle, has implemented a development and implementation project on the gradient of the inter-sectoral coordination of rehabilitation for patients in chronic heart disease courses conducted in cooperation with the Municipal Health Centre, Denmark. The project was financed by the Region of South Denmark through the Danish Health and Medicines Authority. Implementation of a nurse hospital-based case manager is shown through the project to reduce dropout and opt-outs under the sectoral transition significantly.

[Aorta-caval fistula as a complication to abdominal aorta aneurysm]

An 84 year-old man with a history of mild well-controlled hypertension was admitted acute with severe chest and epigastrial pains, radiation to the back and nausea lasting one hour under the diagnosis acute coronary syndrome. Acute computed tomography of the thorax and abdomen showed an 8 x 10 cm infrarenal abdominal aorta aneurysm with a 10 mm fistula through the wall of the aorta into the inferior caval vein.

Short-term Study of the Uptake of PrPSc by the Peyer's Patches in Hamsters after Oral Exposure to Scrapie

The disease-associated prion protein (PrP(Sc)) has been detected in the ileal Peyer's patches of lambs as early as one week after oral exposure to scrapie. In hamsters, the earliest reported time of PrP(Sc) detection in the Peyer's patches after oral exposure to scrapie is 69 days post-infection. To evaluate the acute uptake of inoculum and to investigate whether the Peyer's patches constitute the primary site of entry for scrapie after oral exposure, hamsters were each exposed orally to 1 ml of a 10% brain homogenate from hamsters in the terminal stage of infection with the 263 K strain of the scrapie agent. PrP(Sc) was demonstrated in the Peyer's patches only a few days after exposure, i.e., much earlier than previously reported. This study supports the view that the Peyer's patches constitute at least one of the primary entry sites of PrP(Sc) after oral exposure to scrapie.

KATP-channel-induced vasodilation is modulated by the Na,K-pump activity in rabbit coronary small arteries

The purpose of the study was to evaluate the importance of the Na,K-pump in relaxations induced by K(ATP)-channel openers in rabbit coronary small arteries. Arterial segments were mounted in myographs for recording of isometric tension. Whole-cell patch clamp was used to assess K(ATP)-channel currents in isolated smooth muscle cells from the arteries. In arteries preconstricted with the thromboxane A(2) analogue U46619 pinacidil and cromakalim induced concentration-dependent relaxations. In arteries preconstricted with potassium (124 mM) only high concentrations of pinacidil had a small relaxant effect. In arteries preconstricted with U46619 pinacidil-induced relaxations were unaffected by pretreatment with N(omega)-nitro-L-arginine (L-NNA) and only slightly reduced after mechanical removal of the endothelium. Pinacidil induced relaxations were not significantly affected by 1 microM glibenclamide. However, the relaxations were partly inhibited in potassium-free media and by 1 microM ouabain. In contrast, the concentration-dependent relaxation to cromakalim was partly blocked by 1 microM glibenclamide and partly by 1 microM ouabain and when both drugs were present the inhibition increased. Ouabain (1 microM) and glibenclamide (1 microM) each partly inhibited an ATP-sensitive current induced by pinacidil and cromakalim. In the presence of both inhibitors a greater inhibition was seen. When the solution in the patch pipette was sodium-free the current was reduced and ouabain had no effect. The study suggests that the relaxation to cromakalim and most likely pinacidil is mediated through opening of K(ATP) channels. Inhibition of the Na,K-pump, however, may change the local environment for the K(ATP) channels (i.e. increases the ATP/ADPratio and/or decreases the transmembrane potassium gradient), which partly prevents the activation of the K(ATP)-channel current.

Effects of oophorectomy on functional properties of resistance arteries isolated from the cancellous bone of the rabbit femur

Information is sparse concerning the effect of oophorectomy (OOX) on bone vascularization and blood flow of possible significance for altered remodeling. Whether OOX affects functional characteristics of isolated bone resistance arteries was investigated. Ring preparations (diameter approximately 250 microm) of small femoral bone arteries from oophorectomized and sham-operated rabbits were mounted on a myograph six weeks postoperatively. Cumulative concentration response curves were obtained for various agonists at a normalized lumen diameter. Oophorectomy did not significantly influence lumen diameter, maximal response to high potassium, or maximal response to high potassium and 10(-5) M noradrenaline. However, OOX significantly increased the maximal response to noradrenaline (OOX 2.14 +/- 0.36 N/m, Sham 1.25 +/- 0.14 N/m) and endothelin-1 (OOX 1.76 +/- 0.32, Sham 0.95 +/- 0.15) in metaphyseal arteries. Moreover, the corresponding maximal active pressure for the agonists was significantly increased. OOX did not influence endothelial function assessed by the effects of acetylcholine or substance P. The functional responses of diaphyseal arteries were unaffected by OOX. The study demonstrates regional differences in the effects of OOX on small arteries of importance for control of vascular resistance in bone which suggests a relation between altered vascular function after ovarian hormonal withdrawal and the changes in bone turnover associated with osteoporosis.

The effect of oophorectomy on mechanical properties of rabbit cerebral and coronary isolated small arteries

OBJECTIVE

Our purpose was to study the effect of oophorectomy on the passive and active mechanical characteristics of rabbit small cerebral and small coronary arteries.

STUDY DESIGN

Ring preparations of small cerebral and small coronary arteries from rabbits that had undergone oophorectomy and sham operation were mounted on myographs 6 weeks after operation. Experiments were performed as follows. (1) concentration-response relations for vasopressin (10(-11) to 10(-7) mol/L), U46619 (10(-10) to 10(-6) mol/L), 5-hydroxytryptamine (10(-7) to 10(-5) mol/L), and endothelin (10(-13) to 10(-7) mol/L); (2) relaxing effects of acetylcholine (10(-8) to 10(-4) mol/L); (3) length-tension relations after addition of high potassium (124 mmol/L), vasopressin (10(-7) mol/L), and a mixture composed of potassium (124 mmol/L), vasopressin (10(-7) mol/L), and prostaglandin F 2 alpha (10(-5) mol/L); (4) calculation of vessel morphologic features and determination of hydroxyproline as a measure of collagen content.

RESULTS

Oophorectomy did not influence basal tone, relaxant effects of acetylcholine, vessel morphologic features, elastic characteristics, or hydroxyproline content of the vessels. However, in cerebral arteries at a normalized lumen diameter, oophorectomy induced a marked increase in the force development after stimulation with agonists but not after depolarization with high potassium. The reason for this was a leftward shift in the active length-tension curves (vasopressin activation). In coronary arteries none of these changes were seen after oophorectomy.

CONCLUSION

These data demonstrate that withdrawal of ovarian hormones changes the position of the active length-tension curve for pharmacomechanical but not electromechanical coupling of small cerebral arteries without interference with the elastic characteristics of these vessels.

Angiotensin-converting enzyme activity and contractile effects of angiotensin I and II in human uteroplacental arteries

OBJECTIVE

Our purpose was to study local angiotensin-converting enzyme activity and the mechanical effects of angiotensin I and II in human uteroplacental arteries.

STUDY DESIGN

Angiotensin-converting enzyme activity was measured by a simple radioimmunoassay with tritiated benzoyl-glycyl-glycyl-glycine as substrate in isolated human intramyometrial arteries from nonpregnant (n = 8) and term pregnant women (n = 8) and placental (n = 8) stem villous arteries. Moreover, in these vessels the mechanical effects of angiotensin I and II were investigated in organ bath experiments. Endothelium-intact and endothelium-denuded arteries were used, and the integrity of the endothelium was examined by histologic studies.

RESULTS

The activity of angiotensin-converting enzyme ranked the intramyometrial arteries from pregnant women >> intramyometrial arteries from nonpregnant women > fetal stem villous arteries. Angiotensin-converting enzyme activity was unaffected by removal of the endothelium. Angiotensin II 10(-5) mol/L produced contractile responses in the intramyometrial arteries without significant differences between arteries from nonpregnant and pregnant women. In fetal stem villous arteries the effects of angiotensin II 10(-5) mol/L were less pronounced. As for angiotensin II, the contractile responses to angiotensin I 10(-5) mol/L showed marked development of tachyphylaxis. In the endothelium-denuded preparations the contractile responses to angiotensin I 10(-5) mol/L were significantly enhanced in intramyometrial arteries from nonpregnant women but remained unchanged in intramyometrial arteries from pregnant women and in fetal stem villous arteries. In all preparations pretreatment with captopril or perindopril (10(-5) mol/L) markedly reduced angiotensin-converting enzyme activity, whereas no effects were observed on the contractile responses to angiotensin I. Saralasin 10(-5) mol/L completely abolished the contractile responses to angiotensin I and II.

CONCLUSION

Local angiotensin-converting enzyme activity in human intramyometrial arteries seems to be markedly increased during pregnancy and shows marked differences between maternal and fetal uteroplacental arteries. High concentrations of angiotensin I may imply direct effects on the angiotensin II receptor independent of the local angiotensin-converting enzyme activity.